II THE PATIENT JOURNEY
Avoiding unnecessary admissions
- In tracing the patient journey we start from a place often ignored in discussions of the problem of delayed discharge: the individual in the community prior to hospitalisation. Preventative interventions could have a very considerable impact on delayed discharge by stopping people inappropriately entering acute hospitals in the first place.
- Much of the evidence we received related to managing delayed discharges once they had occurred. References to the importance of 'whole systems approaches' were numerous but relatively few examples of active management to avoid inappropriate hospital admissions were offered to us in evidence. Some general pointers were identified by the Audit Commission which emphasised the importance of providing more preventative care and support for older people judged to be at risk in order to reduce the numbers coming into hospital in the first place. The Commission suggested that there needed to be proactive gatekeeping to screen out people at Accident and Emergency (A&E) departments who did not need to be admitted.
- We were impressed, during our visit to Bedford by examples of what could be achieved by inter-agency co-operation - the acute NHS Trusts, PCT and Social Services working together and actively involving the independent sector. Their strategy was to develop programmes to:
· maintain older people's independence at home;
· contain crises;
· prevent inappropriate admission at A&E; and
· plan discharges together with home support;
- The Bedford Hospitals Trust and the Heartlands Primary Care Trust in Bedford and local social services jointly commissioned screening and assessment in A & E by liaison nurses and senior social workers to prevent unnecessary admissions. The team had access to emergency care packages of up to 72 hours. Partly as a consequence of the fact that GPs and nurses had direct access to respite and rehabilitation beds, the Trusts estimated that 565 bed days had been saved in the six months from January 2002.
- In Wigan, according to written evidence we received, joint commissioning between the NHS and the local authority has led to the establishment of a rapid response team comprising nurses, therapists and a social worker, that accepts referrals from the Accident and Emergency department, all GP practices and the Medical Admissions Unit. On top of this assessment, intermediate care and rehabilitation centres have all contributed to an approach which has minimised delayed discharges, a fact mirrored in the low levels of delayed discharges obtaining in Wigan.
- The King's Fund is undertaking research into the potential benefits, both to patients and in terms of saving bed days, which might arise from targeting services at, and working intensively with, people vulnerable to hospitalisation. They drew our attention to work they had carried out examining winter pressures within London as part of a service development programme mounted by the London NHS and Social Care Office, with King's Fund support. This study had illustrated the benefits of close monitoring of people with chronic respiratory disease, who are likely to be at risk of developing severe illness in the winter months. The research indicated that much more could be done to stop people ever reaching crisis point in the first place. Emergency admissions show peaks in demand in December/January that are entirely predictable; a large proportion of these admissions are older people with chronic respiratory disease. The King's Fund pointed out that many hospital avoidance schemes still focused on "people experiencing some sort of health crisis". The NHS would benefit from acting pre-emptively, before the crisis has taken place. As Janice Robinson, Director of Health and Social Care, The King's Fund told us improvement would be:
"entirely possible if we worked in a very different way, which we have not done in this country, and target those people who are known to the services, they are known to their GPs, they are known quite often to social services and community health as people who have chronic respiratory disease, who are likely to be at huge risk of developing severe illness in the winter months, and there is a whole range of things you can do over and above making sure they have their flu injections. The kind of things Age Concern are saying - putting in intensive care packages of care and support, including improving housing, so that they do not get cold and damp."
- We recommend that the Department of Health identify and publish examples of good practice in promoting avoidance of inappropriate admission to hospital. We would also like further guidance to be issued to trusts to stress the importance of strategies preventing unnecessary admission as a key component of policies to deal with delayed discharge.
Pre-admission, admission and assessment
- Many of our witnesses emphasised that delayed discharges did not, in general, occur suddenly, and that planning for discharge sufficiently early in the process could prevent many of the difficulties that arose. This is important, not least because it points to the factors at different stages of the journey that influence what eventually happens when patients are being prepared for discharge. Mr Richard Humphries, Head of the Health and Social Care Change Agent Team, for example, told us that:
"In every part of the country there should be an agreement between the health service and social services about what procedures should be followed about discharge. Good practice means that in many cases the actual process of assessment should begin when the person is actually admitted because it will be clear that, if for example an elderly person is facing major surgery, they will not be able to be discharged without some sort of care or support. These days we encourage colleagues to view discharge not as an event, but as a process which does require careful planning and the earlier that starts in the person's stay in hospital, the better it will be."
- Professor Ian Philp, National Director for Older People's Services at the Department, explained how the new requirements associated with the introduction of the Single Assessment Process should improve the sharing of information between the community and hospital. Where primary care and social services staff have had contact with a patient prior to their admission to hospital, they are in an ideal position to pass on vital information. This relates to factors such as a person's housing situation, level of mental functioning or physical impairment, and other circumstances that could have an influence on their capacity to live independently following discharge.
- Building on the foundation of such information, good practice would be for well organised, multi-disciplinary processes to operate within the hospital to ensure that a 'whole systems approach' is adopted. As Professor Philp explained to us, this does not mean that in every case, every member of the multi-disciplinary team would need to contribute to the assessment, but that the appropriate skills and knowledge needed to be available as required. The National Service Framework (NSF) for Older People emphasised that planning for discharge should start prior to the hospital stay for planned admissions, and as soon as possible during the stay for other admissions, building on and adding to any assessments undertaken prior to admission.
- The NSF also addressed the need for specialist old age multi-disciplinary teams to include a range of core members including: consultants in old age medicine; specialist nurses or nurse consultants; physiotherapists, occupational therapists, speech and language therapists; dieticians; social workers/care managers, and pharmacists.
- Despite Professor Philp's reference to multi-disciplinary working, and on-going care management and review of the patient as "standard good practice", we nonetheless received evidence to suggest such practice was often not followed, and long intervals sometimes occurred between multi-disciplinary ward meetings, with inevitable delays to the appropriate care and discharge of patients.
- When we were in the USA we were struck by the effectiveness of the strategy adopted by Tufts Healthcare, a major health maintenance organisation, where a single named contact took responsibility for the patient from the moment of admission, up to discharge from the hospital, then on to the care setting or home return. An extremely proactive strategy was adopted. Visits were made to patients' houses to arrange for adaptations and equipment to be put in place even before a patient had undergone hospital treatment. Obviously, it was in the interests of a medical insurer to minimise the length of hospital stay, but we were struck how this financial imperative could also act in the patient's interest.
- We believe that there is great merit in having a named person responsible for co-ordinating all stages of the patient journey up to and beyond discharge, and ensuring that all necessary arrangements are put in place at the right time. We develop this model more fully below.
The hospital stay
- During a patient's stay in hospital numerous structural and organisational issues can contribute to delays in discharge. The Audit Commission, a body which, through its study of local problems, has very considerable knowledge of problems caused by poor bed management, identified a number of ways in which procedures could be streamlined:
· Generally, discharges could be planned earlier.
· Improvements could be made in the timing of decisions that patients were medically fit for discharge, since waiting for consultant ward rounds introduced delays.
· Arrangements for patients to take home drugs could be better co-ordinated.
· Patient transport could be more effectively scheduled.
· Special discharge lounges could be introduced to free beds earlier.
· Consideration should be given to the introduction of discharge co-ordinators, or teams who could play a key role in supporting other staff in planning good discharge arrangements.
- The value of such approaches has long been recognised, but there remains enormous scope for improving procedures. Mr Andrew Webster, Director of Public Services Research for the Audit Commission, pointed out that it was an immensely complex process to take people through all the stages of discharge, and improved co-ordination constituted a vital element.
- While some of the proposed refinements might appear straightforward the impact of such streamlining in practice speaks for itself. St Mary's Hospital, Paddington, for example, established a discharge team and, according to Mr Webster:
"the number of delays has fallen very, very substantially, the number of days lost has been half to a third what it was before, so certainly it is possible to smooth the process in a way that yields real results. And there is no reason to believe that would not be true in lots of hospitals, because the processes, conceptually, are relatively similar."
- One reason, perhaps, why insufficient attention has been directed to such processes is that, as Mr Webster also argued, there are no incentives to encourage it, and indeed "there is too much of an incentive to pass the responsibility to somebody else in the hospital rather than to ensure that the patient moves to another, more suitable place". We return to the question of appropriate incentives below at paragraph 159.
- Other witnesses also identified poor access to diagnostic or therapeutic procedures within the hospital as significant causes of 'blockage' in the discharge process. Ealing Hospital NHS Trust, for example, pointed to "numerous incidences" where the wait for investigations such as endoscopy, feeding tube insertion or ultrasound was the sole reason for delaying discharge. Tackling these problems is not always simply about improving procedures. For example, Ealing Hospital has acquired a new CT scanner which has reduced the waiting time for scans, but the CT is still under-used because of the lack of availability of critical staff, particularly radiographers and radiologists. Ealing Hospital argued that such difficulties were 'typical' of the way the NHS has traditionally been funded, "where a new capital development often comes without due attention to the revenue funding required to maximise the potential of the new equipment".
- Unnecessary stays in hospital of themselves exacerbate the problem of delayed discharges: as is widely recognised, hospitals are not healthy environments. First, hospital stay carries the physical risk of infection. A recent National Audit Office report estimated that around one in 11 hospital patients at any one time has an infection caught in hospital, and that the old and young are the most vulnerable groups. Hospitalisation also carries the risks of institutionalisation and of patients losing independence. Many witnesses emphasised the importance of avoiding hospital admission wherever possible, not least because of the risks people faced as in-patients. The National Pensioners Convention, for example, highlighted the issues of poor quality care that could lead to incontinence, pressure sores, and loss of postural control, alongside the major problem of infection:
"Figures show that hospital acquired infections cost the NHS around £1 billion per annum. Around 5,000 deaths every year are directly caused by hospital acquired infections and a patient with an acquired infection stays on average two and a half times longer than an uninfected patient, an average of an extra 11 days."
- In acknowledging that there are factors within the hospital that can contribute to delays, the Royal College of Nursing (RCN) paid particular attention to the timing of consultant ward rounds. As they pointed out, many hospitals overcame potential problems here by giving the wider clinical team authority to discharge patients, rather than relying solely on the availability of the consultant. In the view of the RCN, nurses were well placed to operate as discharge co-ordinators, but needed to be given the appropriate powers to make decisions. Where this worked well, the familiar problems of administrative delays in the system could be avoided, as Mr Brian Dolan of the RCN explained:
"The vast majority of patients who are discharged will be discharged on the drugs they are on the day before they are discharged, so it does not make sense for the poor individual to be told that, at 9.30 in the morning 'we'll let you go now', for the house officer who is on the ward round not to make it back until half past two, to then wait for another four or five hours for their drug prescription to be filled, and then find actually there is no ambulance, or there is no hospital transport to get them home. A discharge co-ordinator, who has got the decision-making power to ensure those things do not happen, ensures timely discharges and also facilitates the process for the hospital."
- Further problems within the hospital are associated with very high occupancy rates. The National Beds Inquiry demonstrated that the number of hospital beds has been falling steadily over the long term. Length of stay has been reducing (by 3.3% per annum on average between 1980 and 1994 in the general and acute sector), and hospitals have been running at a greater intensity, with an increase in occupied beds. Difficulties arise when bed occupancy exceeds 85%, according to research commissioned by the Department from York University. Yet bed occupancy in the NHS, according to the Department, is currently running at almost 90%. As a result, emergency patients are frequently spread over the hospital in any available beds ('outliers'), and the impact of this, as the Royal College of Physicians (RCP) observed, is that good integrated, multi-disciplinary teamwork becomes "incredibly difficult and frustrating with patients on inappropriate wards".
- Both the RCP and the British Geriatric Society also argued that some of the internal hospital factors that led to delays were a (perhaps unanticipated) consequence of the welcome reductions in the hours worked by junior hospital doctors, and the shorter time available to communicate with patients and relatives. The RCP contended that a national system of Physician's Assistants and Discharge Co-ordinators needed to be put in place.
- We did encounter some evidence of imaginative approaches being adopted in the co-ordination of discharge. For example, at Peterborough Hospital, which has a long history of innovation in this area, the ward staff contact adult social care or a 'transfer of care' liaison nurse as soon as it becomes apparent that the patient may need support either at home or in a residential/nursing home. The 'transfer of care' liaison nurse will then arrange to meet the patient and relatives to discuss such matters as the finding of a suitable home and arrange liaison with a social worker if a package to meet needs is required. In another initiative, the City Council at Peterborough has ringfenced £44,000 to pay domiciliary care providers a maintenance payment for the first fortnight of a service user's hospital admission. This ensures that service users admitted to hospital who do not require a full reassessment are able to be discharged immediately they are ready to their former care provider and care workers.
- Clearly, individual trusts will need to develop their own systems for co-ordinating discharge but there seem to us, from the evidence we have reviewed, to be certain clear principles on which such systems should be founded. There needs to be:
· A care pathway established and monitored
· Clear and agreed clinical protocols for the authority to transfer or discharge
· Planning ahead to establish what the options and possible destinations are
· Support at the destination
· Consideration at an early stage of the mechanics of discharge in terms of ready access to the necessary transport, medication, escort arrangements and reception at the destination
· An understanding that any adaptations will be made and the necessary equipment provided as quickly as possible and well before the patient is fit for discharge
- In addition, a whole systems approach (which we advocate below at paragraph 169) is vital in both the prevention of inappropriate hospital admission and the co-ordination of smooth discharge. Many different branches of health and social care are involved, including the GP and community team, hospital and community nurses, agencies, hospital pharmacies, hospital clinicians and occupational therapists. The voluntary sector may also have a role to play. Friends and relatives, who may well be carers, need to be fully engaged in these arrangements. Even more pertinently, the patients themselves should be partners in the discharge process. In this regard, we note the point that Age Concern England have made that the Government definition of "delayed discharge" excludes "any involvement by the patient or carer in the decision".
- We believe it is essential that patients should as much as possible be partners in the discharge process. In circumstances where they lack capacity they should have access to advocacy services.
- We are convinced that arrangements for the management of discharge need radical overhaul in many hospitals. In our view, best practice involves a multi-agency team actively managing all aspects of the discharge process. The leader of this team, we believe, should be jointly appointed by the NHS and councils with social services responsibilities. The team should have clear links with all key points in the patient's journey. These would include: primary care; Accident and Emergency; all stages of the hospital stay; all the interfaces at the point of discharge, including housing; those arranging for equipment and adaptations; social services and care homes. We would expect community nurses to play a key role here and would recommend the practice of appropriately trained, designated nurses within hospitals, having the power to discharge, following pre-agreed clinical protocols, to be adopted. The team would be co-ordinated by the 'patient discharge liaison manager' who would be the point of contact for the patient and their carers, and for all other members of the team. The manager would be responsible for ensuring that all arrangements for discharge and appropriate care were in place, and would not simply be a placement officer ensuring that patients are discharged to care homes. The emphasis needs to shift fundamentally towards proactive rather than reactive responses to discharge: the patient discharge liaison model offers real potential to ensure this is achieved for all patients.
- Finally, even if good systems are put in place there is a danger that they will quickly stagnate and become ineffective or unresponsive to change. We recommend that discharge procedures should be a focused element of clinical governance, and of every CHI review in the NHS. It is also vital that these matters are addressed in inspection procedures both through the proposed new independent healthcare regulator (the Commission for Healthcare Audit and Inspection) and through the equivalent body for social services (the Commission for Social Care Inspection).
- One reason why procedures for discharge vary considerably may be the lack of recent comprehensive guidance from the Department. The Hospital Discharge Workbook is in urgent need of updating. Much has changed since this guide to good practice was published in 1994. We think there is an urgent need to address the avoidance of inappropriate admissions and to locate the discharge process within the wider context of intermediate care development. We also recommend that new statutory guidance on health and social care responsibilities for hospital discharge should be issued as a matter of urgency.
- Delayed discharges of themselves are unwelcome. But it was apparent from our witnesses that a parallel problem existed in respect of discharges that occurred prematurely, in too much haste and with insufficient planning, as a consequence of the pressure on acute hospital beds. Age Concern England pointed out:
"Age Concerns around the country report cases where older people are hurriedly discharged home without the appropriate care being put in place because of the need for hospital beds to be freed up quickly. 'Late Friday afternoon discharges' were often mentioned as patients are discharged when no one is available to set up services over the weekend. Often relatives complain that they are given little or no notice that the person is to be discharged, which can mean that they return to a cold house, with no food, and have to wait for an assessment from social services. Similarly there are complaints about lack of information from the hospital about the care or medication required."
- Evidence from Carers UK highlighted similar concerns. They told us that their research, based on the experiences of over 2,200 carers, "suggested that many carers were left to cope in the community with unacceptable caring situations". They compared findings from research undertaken by Carers UK in 1998 with work conducted in 2001, which indicated that the proportion of respondents experiencing readmission within two months of discharge had more than doubled from 19 to 43 per cent. As Ms Whitworth remarked, while it could not categorically be concluded that early discharge was the reason for the rise in re-admissions, such a link did appear plausible, and "the proportion of carers who felt that the person they were caring for had been discharged too soon rose from 23 per cent to 45 per cent".
- We are concerned that the focus on tackling delayed discharges, entirely laudable in itself, could lead to an intensification of pressures to discharge patients too quickly, with inadequate preparation, and in situations that could intensify the demands on their carers. This has the potential to trigger a rise in readmission rates. Premature discharge leading to readmission is clearly stressful and in many cases harmful for the patient, and is also wasteful of resources. High levels of unplanned readmission are likely to be a marker for poor practice.
- A key plank of Government policy, as we have already noted, lies in the development and expansion of intermediate care, care which can bridge the gap between hospital discharge and achieving optimum independence for the individual.
- We were keen to establish what progress was being made towards the establishment of 5,000 extra intermediate care beds in community or cottage hospitals or specially designated wards in acute hospitals, promised in the NHS Plan, and to establish the extent to which extra care beds were easing delays in discharge. Despite the apparently clear description of the role of intermediate care contained in the Plan, we discovered that problems arose in defining what was meant by this term. Professor Philp told us that intermediate care services were intended to 'bridge the gap' between hospital and home; people should not be in hospital longer than necessary, but in most cases their needs were not going to be met by a move to long-term care and most wanted to go back home. Other witnesses portrayed intermediate care as services that facilitated a shift from medical dependence to functional independence. This could include preventative, pre-hospital, and post-discharge elements of support.
- The service models that were likely to satisfy the criteria set out in the Department's Circular on intermediate care (see above, paragraph 38) comprised rapid response teams to prevent avoidable acute admissions; hospital at home schemes, to avoid acute admissions or enable earlier discharge; residential rehabilitation; supported discharge; and day rehabilitation. If the range of different models is to work successfully, and satisfy the criteria of the guidance, considerable diversity will be required, albeit within a highly strategic and integrated care system. As Professor Cameron Swift of the British Geriatrics Society told us, making this operate presents a major organisational problem:
"We do not see ... the signs of that organised approach to a locally sorted, intermediate care service coming into place, and we believe that has got to happen, you have got to develop an organisation, preferably manned by a group of signed-up, committed professionals, who are the leaders of the service, and who actually take advantage of the diversity and actually sort out where it fits in and what it has to contribute ... There is a major organisational problem with intermediate care, which is why, at the moment, there is no evidence in any global sense that it is helping the problem of delayed discharge."
- Witnesses generally welcomed the new resources that were being directed into intermediate care and building capacity. However, as the Audit Commission suggested, getting the most out of these initiatives will be a challenging task, and one demanding a change of culture. Authorities and trusts, they argued, needed to adopt a whole systems approach that would reduce demand, facilitate smooth discharge arrangements, rebalance services where necessary and co-ordinate care at both operational and strategic levels.
- Addressing all of these elements simultaneously is far from straightforward. In many respects, the easiest response would be to use extra funding simply to provide more beds. In the view of the British Medical Association, however, merely using the resources in this way would mean "an opportunity would be wasted". Dr Morgan, for the NHS Confederation, described the difficulties of trying to change the nature of the health service, and specifically of investing "more in the community sector and less in the acute sector", with the latter being used for people really in need of high technology care:
"The issue, once you have your money in there, is how to get it out to develop these new alternatives. You need the alternatives before you can get rid of the beds in the acute sector."
- Dr Morgan also commented on the inappropriate use being made of community hospital beds. The situation varied because not all areas had such beds, but where they existed they could be used to manage delayed discharges. What this often amounted to, in Dr Morgan's opinion, was "moving people around the system, moving them to a level of care which may be higher than they actually need rather than using them appropriately". It is difficult to know what is happening on a national level, because figures are not collected on delayed discharges in community hospitals. Some of the activity in community hospitals is targeted at avoiding admission to acute or long-term care and supporting early discharges from acute hospitals, but as Dr Morgan pointed out, "some of it is about care which could be provided in other places or in people's homes. Once you put a bed somewhere, there is a tendency in the system for clinicians quite appropriately to put people into the bed".
- Research from the NHS Confederation indicated that 40% of the people in community hospitals would be cared for at home if no such facilities were available. It seems to us that community hospitals are an important provision and should be a resource centre, not only for appropriate support beds but for outreach in the development of appropriate community facilities and intensive home support. This approach necessitates getting people to think differently, so that the community hospital is used appropriately, and staff with the right skills provide the support required. Dr Morgan told us that evidence from stroke audit across the country demonstrated that the majority of community hospitals were not as effective at rehabilitating people who have had strokes as acute hospitals, because they were not geared to intensive rehabilitation. In Dr Morgan's view, there was currently a vicious circle, with money going into beds actually preventing patients from accessing appropriate care:
"You need to break the loop somewhere to take the money out of beds, to put it into the people, to look after people in their own homes, to avoid the admissions and then to allow you to get staff in the hospitals and the beds we have more geared up to provide more intensive packages so that people can genuinely be rehabilitated into their homes. The problem is that once you have a bed it will be used, anywhere in the health system it will be full, because that is the way the system is geared to respond."
- Dr James, for the NHS Alliance, told us that a focus on "building capacity just for capacity's sake, because we need it", was putting the emphasis in the wrong place:
"Rather than getting into the treadmill of being medicalised, being in hospital, being institutionalised maybe, then requiring residential care, we really need to be looking at the alternative referral destinations, alternative treatments, treatments from home, keeping these people out of hospital so they are not in this situation. Rather than building capacity with
the inherent dangers of warehousing elderly patients because it is a tidy solution to a crisis, we need to be building individual care plans to keep them independent and hopefully well in the future."
- In our view, building capacity, whether in the acute sector, in community hospitals, or in residential and nursing homes, essentially risks feeding the problem of delayed discharges and ensuring that it is self-perpetuating. Breaking the cycle demands the simultaneous development of alternative facilities in the community to ensure that inappropriate admissions can be avoided and timely discharges supported. We believe that the way targets are structured and monitoring takes places forces a preoccupation with short-term objectives, such as relieving pressure and reducing delayed discharges. To achieve long-term success in this area the reconfiguration of services needs to be addressed.
- Despite the allocation of additional funding for the development of intermediate care, witnesses expressed concern about resources being 'siphoned off' for other purposes, or being prioritised for uses that did not support intermediate care and rehabilitation. As the King's Fund remarked:
"it seems that a proportion of the funding expected by local NHS bodies is being used for other purposes, eg to meet increased salary and prescribing costs. In the case of local authorities, there are indications that priority for limited resources is being given to long-term care, rather than short-term help with rehabilitation."
- In the light of such practice, The King's Fund concluded that the pace of development of intermediate care services had been "disappointingly slow". Poor practices had grown up, including inappropriate placements "made solely to relieve pressure on acute hospital beds", and - as other witnesses also noted - there has been a 're-badging' of existing services, and this may be occurring at significant levels. If this is the case, the scale of new intermediate care development that the Government claims is taking place may be inflated. As Janice Robinson observed, there are dangers in attaching the label of intermediate care to a diverse range of services:
"The danger is that by putting a label on it and saying you will give most of the new money for that, it allows people ... to dive in and see that as the panacea for everything and they re-badge 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."
- Westminster Health Care similarly noted that there had been "few attempts to involve the independent sector in providing additional services, with much of the money going in re-opening closed wards with the new title of intermediate care wards". The Continuing Care Conference (CCC), a coalition of commercial, charitable and public service organisations committed to providing better care for older people, also drew attention to such 're-badging'. Although evidence is anecdotal, there are widely reported instances of NHS wards being opened that are nominally intermediate care wards, but which, in practice, "are either wards which have previously had to close or were about to close. So, 'new' facilities are merely restoring the status quo in terms of resources". However, the Audit Commission argued that the evidence on 're-badging' needed to be counterbalanced by other evidence that pointed to a wide range of different approaches, some of which were genuinely multi-disciplinary, and which were effective in preventing hospital admission and enabling people to become more independent.
- We are concerned about the practice of 're-badging' NHS services as intermediate care. We do not know how widespread this practice is, but it was drawn to our attention by witnesses from different backgrounds and perspectives. We recommend that the Department needs to address this issue. If re-badging of services is widespread, this is both a misuse of the resources identified for the development of intermediate care, and represents a failure to utilise the skills, knowledge and wider experience of statutory and independent sector partners for maximum benefit. The potential of intermediate care will not be realised if this more limited vision is allowed to develop.
- Criticism of the special funding for intermediate care was levied by the SPAIN group (a consortium of over 30 voluntary organisations of and for older people). In particular, SPAIN objected to the fact that the funding was intended only "to meet the short-term needs of older people discharged more quickly from hospital or avoiding admission". Intermediate care, according to the guidance, was not expected to exceed six weeks, with the norm being one or two weeks. However, people's support needs would not necessarily end at this time:
"Many of those who are helped to return home or to stay at home will need much longer term support from social care services in order to live independently, in many cases life-long. It is far from clear where these extra funds are going to come from."
- Ms Helena Herklots, Head of Policy for Age Concern England, told us of anecdotal evidence that was building up from local Age Concern groups which indicated potential difficulties with time-limited intermediate care, of "a higher than average rate of readmissions [which] seem to be occurring at about the time intermediate care ends". Ms Herklots suggested that there was a need for "another step down service after intermediate care". In her view, even when medical issues had been dealt with, there remained the challenging and complex task of patients regaining confidence; intermediate care needed to develop further to address such transitions. Some local Age Concern groups, she told us, had developed such projects, for example providing a visiting and befriending 'forget me not' service.
- The Audit Commission, on the other hand, argued that the time-limited principle was a very important one: "if it is intermediate it has got to be from somewhere to somewhere, has it not, rather than ongoing".
- Age Concern England also emphasised the distortions caused by the concentration on delayed discharges. They felt that there were risks that an over-emphasis here would mask "another equally serious but much more invisible problem of those in their own homes who suffer delays in getting the services they need, from health or social services or housing". The additional funding, and the pressures on local authorities to use it to tackle delayed discharges, might exacerbate the diversion of funds away from those who have long-term needs in their own homes "but who are not at immediate risk of going into hospital or have not recently been discharged". Other groups of people occupying a hospital bed are also unlikely to benefit from intermediate care.
- While we recognise the value of targeting additional resources through special grants, and focusing on under-performing authorities, we also accept that this can appear to reward poor practice. We recommend that, in line with the Government's emphasis on 'earned autonomy', there should be a corresponding development of support to authorities that are performing well, which gives them freedom to use additional resources in the way that most suits their local circumstances.
Partnership with the Independent Sector
- The Cash for Change resources have been allocated so as to build not only capacity but also partnership between the statutory and independent sectors. However, we were repeatedly told by independent sector providers that, notwithstanding the Concordat between the NHS and themselves, such partnership was rarely in evidence. While they welcomed the emphasis on intermediate care, and the endorsement of the role of the independent sector, the Independent Healthcare Association (IHA) was critical of the rate of progress and observed:
"it appears that the funding issues, the necessity for a commitment to joint working and the failure to include the independent sector in the planning processes have all contributed to this lack of progress."
- The IHA's view was that, despite the potential of intermediate care to promote independence and enable people to return home, successful schemes were few and far between. Independent sector providers reported difficulties in establishing real and continuing partnership arrangements with health and social care: "the frustrations of the providers who have access to the resources and expertise to contribute is immense".
- The IHA argued that the NHS culture was one of ignorance or suspicion towards the potential contribution of the independent sector to intermediate care. In consequence, rather than a real development of capacity, there had simply been a restructuring of existing NHS provision.
- Westminster Health Care pointed to successful initiatives where close working between NHS trusts and the independent sector had occurred, enabling people to be transferred from hospital first to a nursing home, and then, following a planned programme of rehabilitation, to return to their own homes. There appeared to be few examples of the independent sector being involved in the planning of intermediate care services. In the view of Westminster Health Care, given the wealth of experience the independent sector had as the major provider of services, "this neither reflects the concept of partnership working, nor uses the full skill and knowledge" available. This was confirmed by Mr Michael Leadbetter, President of the Association of Directors of Social Services (ADSS), who told us "the private sector are the major players. Unless we properly but robustly engage with them, we are not going to be able to manage this market".
- We believe that it is important that the Government obtains better data on the provision of intermediate care by sector if its plan for 5,000 extra intermediate care beds is to succeed. If the Government is committed to using the independent (private and voluntary) sector, who provide the majority of care, it must ensure that the sector is involved in developing care and support services in which the care home is only one of a range of service options, tailored to meet the diversity of need of individuals. By such involvement, not only will choice be extended, but also the best use will be made of this resource.
- The problems associated with capacity in the residential and nursing home sectors in particular, but also of home care services, were identified by witnesses time and again. The closure of independent care homes has attracted considerable media coverage, but the precise scale and the impact of the closures that have taken place proved very difficult to identify. Several submissions to us mentioned the figure of 50,000 lost beds, although there was considerable variation in the timescale over which this loss was believed to have occurred. However, the 50,000 figure was elsewhere contested. Ms Denise Platt told us that the figure of 50,000 was not a net figure, and did not include the number of new beds that have opened as well as those that have been lost. She considered the net loss to be 19,000 beds. The Prime Minister has also used the figure of 19,000 beds in response to questions on this subject. It is important to establish the true figure, and to understand the basis for the confusion that has arisen.
- The vastly different estimates of numbers of beds lost from long-term care result from different definitions of beds being counted, and from the use of different base years. The following facts and figures are all based on Table 2 below. This table demonstrates that over a long period there has been a continuing reduction in the provision of NHS long stay beds and in the local authority provision of residential care, offset by the continued expansion (until recent years) of private and voluntary nursing and residential care home provision. Taking 1997 as the base, by 2001 the total provision of long-term care places across the public (NHS and local authority) and the independent (private and voluntary homes) sectors reduced by 46,700 places, that is:
Local authority residential: loss of 13,600 beds
NHS long stay (as defined in the Table): loss of 12,500 beds
Private and voluntary homes: loss of 20,600 beds
- Within these figures there has been a growth in private and voluntary residential places of 7,000 but a loss of 27,600 nursing home beds. The figure of 19,000 lost beds which is sometimes referred to, comprises the net loss of 18,924 beds which took place between a different base year, November/December 1996, and November/December 2000. All the figures embrace many complexities, both of definition and usage. For example, the development of care in the community has enabled some institutional care to be replaced by care at home or in appropriate and sheltered housing. If losses are counted from the peak year of provision (1996), there has been a decline overall of 49,700 beds (from a peak of 575,600). This is the origin of the often cited figure of 50,000 lost beds.
- The NHS has continued to provide some long-term care either directly or by contract with appropriate nursing homes. However, a distinctive feature of care home provision by all sectors is that, with the exception of a small proportion of nursing home beds contracted to the NHS, the residents are not receiving continuing NHS care and, on leaving hospital, will have been discharged from that care.
- We therefore consider that a distinction needs to be made between NHS long-term care and care home places - hence the analysis indicated in paragraph 99 above. We conclude that the figure of 50,000 arguably overstates the full losses that have occurred since it includes NHS provision that is different in kind from care home provision. At the same time, however, the figure of 19,000 appears to us to be arguably an under-estimate of the losses that have taken place. If trends in the provision of all care home places (across local authority, private and voluntary providers) are considered, there has been a net loss of 34,200 places (see paragraph 99) between 1997 and 2001.
Table 2: Nursing, residential and long stay hospital provision for elderly, chronically ill and physically disabled people
by sector, UK 1987-2001
Private &Voluntary Residential & Nursing Sub-total
Long stay Geriatric (estimated)
Young physically disabled
Source: Laing & Buisson (2001), Care of Elderly People Market Survey 2001, Derived from Table 2.2
- The figures indicate a pattern of transfer from nursing to residential provision, and dual registration of care homes to accommodate both residential and nursing care. This is likely to reflect the market responding to financial pressures, higher thresholds in nursing care, and the difficulties in attracting sufficient numbers of qualified nurses to nursing homes. Such a trend is a matter of particular concern; the viability of intermediate care policies and short-term rehabilitation is likely to be very dependent on the availability of high-quality nursing input in care homes. Further dilution of nursing capacity will seriously jeopardise the delivery of these objectives in this sector. It is the statutory requirement for registered nurses to be on duty at all times in care homes providing nursing that makes such homes an important option amongst the choices for patients requiring continuing nursing care but not acute hospital provision.
- Capacity pressures are only partly a consequence of the closure of care homes. We also received evidence that some independent sector providers were refusing to accept local authority funded clients because they believed the fees offered were unrealistically low. Age Concern England, for example, told us about homes operating with "differential waiting lists":
"We have heard reports from a number of Age Concerns that if the person is able to fund themselves and pay the full rate for the home, then vacancies are available. However, if the person is a local authority funded resident they are told by the home they will have to wait. We have received one report that this wait is less if the relative agrees to make a top-up of at least part of the differences between what a person fully funding themselves pays and what the local authority will agree to pay."
- By embracing the concept of top-up funding some local authorities have held down their fee levels to ones that would not otherwise have been sustainable. As the Department has acknowledged:
"Providers have become increasingly concerned that some commissioners have used their dominant positions to drive down or hold down fee levels that recognise neither the costs to providers nor the inevitable reduction in the quality of service provision that follows. This is short-sighted and may put individuals at risk. It is in conflict with the Government's Best Value policy. And it can destabilise the system, causing unplanned exits from the market."
- Since the community care changes were introduced in 1993 and local authority social services departments were given lead responsibility for purchasing care, they have occupied a powerful position as the major, and sometimes sole, purchaser of beds and other social care services. The previous administration, as part of the community care reforms fully implemented in 1993, expected local authorities in taking up the funding (following means testing of people assessed for nursing and personal care in registered homes) to use their purchasing power to drive down prices. Social services authorities have used their market power to drive down, and hold down, prices, largely as a consequence of their own resource constraints. The resultant loss of capacity, together with the lack of community-based alternatives, has resulted in the current difficulties in making placements.
- If there are insufficient care home places available in the right area, and at an acceptable price and quality, there will inevitably be delays in placing people who have been assessed as needing such care upon discharge from hospital. As Ealing Hospital NHS Trust remarked, "the result is that many patients are inappropriately 'hotelled' in acute medical beds".
- Several witnesses offered views on the size of the shortfall in fees paid to independent sector providers, and the nature of the increase that would be required to halt the continuing loss of capacity. The IHA, for example, suggested that the shortfall was approximately £64-£89 per person, per week. Other estimates by Laing & Buisson have suggested that a figure closer to £100 would be needed to generate the rate of return on capital that providers would require if they were to remain in the market. Mr Barry Hassell, Chief Executive, IHA, told us that the total annual shortfall:
"is in the region of £1.5 billion, and that clearly is a huge figure, but that is exactly why homes are moving out of the market, because they are no longer viable. Whether you are operating a charity, or whether you are operating a 'for profit' organisation, you cannot sustain homes, either professionally or financially, at those sorts of shortfalls."
- This position has been confirmed in a study undertaken for the Rowntree Foundation which draws on an analysis of the base line fee levels of a county council. This report states that "inadequate fee levels for state funded clients have been a major factor in the decline in recent years in home capacity" and "local capacity shortages have exacerbated the bed blocking phenomenon which in turn threatens the ability of the NHS to deliver on its ambitious programme of reform to modernise the NHS". The principal aim of the report is to provide commissioners of care services with a transparent and reliable means of calculating the reasonable operating costs of efficient care homes for older people in any locality, and thus determining the fee levels necessary to sustain delivery of adequate care services by independent sector providers, now and in the future. The report concludes that a comparison of the reasonable costs of care homes meeting all regulatory and commissioners' requirements with estimated average fees currently being paid by local authorities indicates an additional £1 billion per annum might have to be found to fund a stable care home sector.
- We were told that care home businesses were closing for a variety of reasons. If profits were low, it was very difficult for businesses to be sold within the care home market. In the context of rapidly rising property prices, this meant that many providers were not selling the business so much as selling the building and land for development. For others, we were told that a combination of factors, including the low level of fees, together with the introduction of new and higher standards, had created a situation in which businesses were not viable and had had to close down. Cambridge County Council told us that high local wages and a steep rise in property prices had contributed to local problems. There had been a:
"rapid deterioration in the ability of home care agencies to compete in the employment market and recruit sufficient care staff. During 2000 vacancy levels across the sector ... were at 40%. Three major providers with whom the Council held contracts ceased to trade, unable to cope in this environment."
- The financial impact is also borne by individual service users. We were extremely concerned to hear of some cases which apparently pointed to nursing home proprietors failing to pass on the value of the free nursing care payment to self-funding residents. It appears that some have used the opportunity to 'adjust' the fees charged by at least the equivalent amount that residents receive as a result of the assessment of the registered nursing care contribution (RNCC), (initially a weekly payment of £35, £70 or £110 corresponding to Low, Medium and High bands of need for registered nursing care), leaving the resident no better off, and sometimes even worse off than before the assessment. We understand that financial pressures on care fees will have encouraged some homes to adopt such a strategy, and we are surprised that this eventuality did not appear to have been anticipated by the Department, but we believe this to be contrary to the spirit of the changes introduced to provide NHS funded nursing.
- We are not convinced that the steps that have been taken to require homes to clarify the breakdown of their fees for residents will do anything to redress the situation of nursing homes raising their fees to absorb the value of NHS funded nursing care payments. We urge the Government to take further action to ensure that the full value of the registered nursing care contribution is passed on to residents as intended.
The Choice Directive
- Capacity problems interact with other variables to produce delays (or potential delays) to the discharge process. The so-called 'Choice Directive' requires authorities to allow people to choose a home that suits them, and if the preferred home has no vacancies a placement can be delayed for a considerable time. The Choice Directive recognises the fact that people who are leaving their own home to spend the rest of their lives in a residential or nursing home need time to make important decisions. This is a principle we welcome, but it was clear to us both from the evidence we assessed and from the anecdotal reports we received during our UK visits, that the Choice Directive was a significant component of delayed discharges. According to the Department's own analysis this factor underlay 8.1% of delayed discharges.
- Some witnesses advocated the use of interim placements in situations where permanent placement was likely to be considerably delayed. Mr Leadbetter, for the ADSS, offered the example of arrangements in Essex where, if the first choice of home was not available, a person was placed in another home, while efforts were made to get them moved to the first choice home as quickly as possible.
- However, Mr Leadbetter and other witnesses acknowledged that such strategies would not work everywhere and needed to be approached with caution. Dr Morgan, for the NHS Confederation, pointed out that nurses and social workers would often find it very difficult to encourage people to accept a short-term placement, and in some cases there would be good clinical reasons for avoiding interim placements. For older people in particular, "multiple moves are not a positive health outcome for them and it leads to harm in itself". Moreover, alternative placements could easily become routine, potentially creating a situation where people were simply shunted around the system.
- We accept the need for tact and discretion to be exercised in setting up interim placement schemes for those unable to access their first choice home. However, we believe that if interim schemes are set up in a creative way, offering appropriate care of a high standard, this would be a step forward. We are firmly convinced that hospitals are often inappropriate, potentially harmful, as well as exceedingly expensive places to act simply as staging posts for people awaiting care home placements. So we believe that there should be a presumption that those unable to access their first choice home should wait in interim placement settings unless there are genuine clinical reasons to suggest this would be unwise. Careful monitoring would need to be undertaken to ensure that local authorities did not exploit this artificially to limit access to good quality homes.
- There is scope for developing care at home as part of the spectrum of intermediate care services. However, we have already highlighted the extent to which models of care are being focused on residential/nursing home beds, or care within the hospital. The United Kingdom Home Care Association suggested that one way of counteracting this could be through a new presumption in favour of the provision of all health and care services (acute or long-term) in the patient's own normal place of residence, unless there were "specific, objective justification for admission".
- The policy for community care has long been one of supporting people at home, where this is their choice, and where that can be secured - both in service and cost terms. Registered care homes, including those providing nursing care, are an important element in considering options for care; but that provision should not be regarded as the easy option simply because in a given area the capacity is there. To this extent closure of care home places can act as a further spur to the development of care at home and other responses tailored to the assessment and preferred choices of individuals.
Alternatives to care homes
- In our visits in England we witnessed two schemes which offered dynamic alternatives to the options of residential care, nursing care or care at home.
- We first visited Hartrigg Oaks, a continuing care retirement community on the outskirts of York. It is run by the Joseph Rowntree Housing Trust and offers residents a range of levels of care from home help to nursing care. The accommodation is spread over a 21-acre site and consists of 152 one- and two-bedroom bungalows and 41 en-suite bed sitting rooms in the care centre, known as 'The Oaks'. The bungalows are situated around the Oaks which also boasts restaurants, small shopping facilities, a library and workshops which run an impressive array of activities and hobbies. Residents are able to maintain a high level of independence in the bungalows with a minimum of assistance; over half of the residents require care or aid totalling less than two per cent of their time. 'The Oaks' offers residents high-level nursing care for respite, recuperation and rehabilitation including long-term care. When we visited Hartrigg Oaks its managers told us that the community had had a positive impact on the health services as patients were discharged earlier to the Oaks than to other facilities. They estimated that 384 bed days a year had been saved by early discharge to its facilities.
- Hartrigg Oaks is a private scheme and we were told that it was probably affordable only to the top 30% of the population aged over 70. The fees are separated into two payments, one for occupancy and the other for the community care services. Hartrigg Oaks is very popular, with demand outstripping capacity. We find this unsurprising since in our view it is an exemplary model of progressive community care for those able to afford it.
- We also visited the Berryhill Care Village in Stoke-on-Trent, a sheltered development providing 148 accommodation units for people with need levels varying from the wholly independent to those requiring more intensive personal care. Because of the range of support packages available, if residents do need a hospital stay resulting in reduced independence, care arrangements can be easily adapted to meet new needs within the same environment, facilitating timely discharge with a minimum of disruption. The ExtraCare charitable trust which runs Berryhill also manages a successful interim discharge project based in Kettering. In this scheme, nursing care is provided in a housing-based environment, with the aim of encouraging an early return to independence.
- At Berryhill, all residents are housed in specially designed one- or two-bedroom apartments within a central accommodation block, where differing levels of care can be provided according to individual needs. In addition, there is a range of on-site facilities, including a restaurant and bar, greenhouse, and gymnasium, as well as a shop and a hairdresser. We were impressed by the standard of accommodation and particularly by the high level of resident involvement in the organisation and running of the village, which seemed to facilitate a strong sense of community and empowerment amongst residents. Berryhill has a rather different social mix from Hartrigg Oaks. When Berryhill opened in 1998, 80% of its new residents were in receipt of housing benefit, and only 20% were owner occupiers. Residents currently pay rent, although in future developments the ExtraCare Trust plans to make some apartments available for sale. Most of the 55 support packages currently provided at Berryhill are funded by social services.
- We believe that the Department should closely examine the facilities on offer at Hartrigg Oaks and Berryhill and take note of the emphasis placed on an active community and independent living. We recommend that the Department conducts a cost-benefit analysis to see how the costs of care in such schemes compare with the costs to the state of both additional hospital admissions and stays and the costs of other forms of care.
Developing new models of service
Equipment and adaptations
- As Table 1 indicates, a further cause of discharge delay is the time taken to prepare support at home, and to make the necessary home adaptations and provide equipment. This emerged as a significant issue in our inquiry. Age Concern England pointed out that the Government has recognised the importance of equipment by increasing the funding for community equipment services. However, increasing funding alone will not be sufficient because, in addition to the supply of equipment, "there are workforce and training issues to ensure that there are enough people to assess and review equipment services". The suitability of the home goes well beyond the mere presence of the right equipment; the general fitness of the housing stock can make all the difference as to whether the person can return to their own home.
- Care & Repair England, a charity established to improve the housing and living conditions of older people, emphasised that home improvement agencies and other service providers had developed the capacity to implement quickly and effectively small repairs and adaptations services which could help improve discharge arrangements, and reduce the risk of readmission. This they would do by such measures as improving home safety, preventing falls and repairing heating systems. They went on to point out:
"the vast majority of older and disabled people leaving hospital are returning to ordinary homes in the general housing stock. Ensuring that those homes are fit and adapted can contribute both to fast and effective discharge and also to enabling people to live independently."
- When we visited medical insurers in the USA we were told that rapid action to provide appropriate equipment and adaptations had become a high priority. Here the driver was reducing acute care costs to the insurer, but we believe that there are also great potential health and social benefits to be gained in enabling individuals to live in their or their carer's home wherever possible. At present, however, there are many obstacles to appropriate provision.
- Ms Herklots, for Age Concern England, described the problems her organization had encountered with the Disabled Facilities Grant (DFG) system, "which is an incredibly complex and difficult system for people to manage". The DFGs provide up to £20,000 for major works required because of disability. However, the rules allow six months for the determination of applications, and if approved the work is meant be carried out within a year. As Age Concern England noted, any system which allows delays of 12 months within a system for essential adaptations "is not seriously tackling meeting the needs of older or disabled people".
- Acknowledging that there had been little change since it had published Equipped for Independence in 1992, the Department commissioned a study by the Disabled Living Centres Council and a guide to good practice in disability equipment services was published in 1998. Unfortunately, we encountered little evidence to suggest that its well-disseminated examples of innovative practice have led to any radical improvements in strategic planning, user involvement, information provision, assessment or equipment supply. Accordingly, we welcome the focus of the NHS Plan in requiring the integration of community equipment services by 2004 and the additional funding provided to support this integration. We note its forecast that 50% more users will benefit from these services. Careful monitoring of the success of this strategy will be required if it is to meet these expectations of improved service.
- However, we note that the Audit Commission has recently commented that "for the most part equipment services remain in a parlous state". Moreover, the Commission has found that very little of the new money provided for equipment services appears to have been spent in accordance with Ministers' wishes. Ineffectual commissioning, in the view of the Audit Commission, lies at the heart of the problems relating to equipment services. Service commissioners and providers "generally have no idea about the underlying level of demand for equipment services. Unmet need represents a major cause of social exclusion". There appears to be little recognition of the vital role of equipment services in contributing to the wider strategies to promote independence, and too little linkage of equipment services with wider healthcare objectives.
- We agree with the Audit Commission that further work is needed to provide guidance on the effective commissioning of equipment services to social services, primary care trusts and strategic health authorities. We were struck by the enormous potential of joint initiatives between social services and housing authorities (alongside the voluntary sector) aimed at ensuring that adaptations and repairs are carried out speedily and facilitating the discharge of patients from hospital and their continued independence in the home. However, such practice appears to be very patchy and we recommend that the Government should produce firmer guidance, alongside the dissemination of best practice.
- The need to develop local solutions that include housing offers further support for the argument in favour of a whole systems approach, a point we develop below. Age Concern England argued that only through such an approach would health and social services partners be able to make the connection between the provision of equipment and adaptation and the potential savings to their own budgets, the sort of connection that US medical insurers were much better placed to make. Clearly, however, this awareness is one that requires imagination and vision, and such qualities vary considerably between different authorities and areas.
- Our visits to Peterborough, Bedford and Northampton suggested that a significant obstacle to the prompt installation of equipment in the home arose from the need for assessments to be undertaken by Occupational Therapists (OTs). While the necessity for bath-rails and similar equipment might appear self-evident, and the need for formal assessment an unnecessary delay, witnesses were nonetheless cautious about how easily a 'common sense' approach might be substituted for formal assessment. As Ms Herklots commented:
"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."
- We acknowledge that this is a prudent approach but we believe that more flexibility is required to give impetus in this area. We recommend that other health professionals should be given training to support these initiatives in areas where Occupational Therapist shortages are causing unacceptable delays in the installation of essential equipment.
Technology to assist staying at home
- An area in which there is enormous potential for the development of new models of support is care at home. The United Kingdom Home Care Association (UKHCA) described to us flexible and innovative services that could complement and extend existing provision. In addition to nursing care that could be provided by home visits, there was the potential for the development of new services:
"where the main need is to take regular observations (by telemonitoring), by higher dependency services, where equipment is becoming ever more portable and by fast response services to shorten stays or avoid admission completely."
- The provision of high-technology services in the home necessitates adequate home support, especially where carers are not available or need to be supported. The UKHCA told us that social services were often not in a position to cover short-term services; NHS district nursing sometimes lacked the capacity to perform this function. Some independent sector providers were at an advantage in that they were able routinely to "deliver the full range of nursing, personal and practical support as an integrated service. Where required, they can also now deliver medical, pharmacy and equipment elements". We return to the wider issue of integrated services later in this report.
- Other witnesses highlighted the actual and potential role of telemedicine and telemonitoring. The UKHCA argued that the combination of home healthcare and telemedicine held the key to achieving really big improvements in capacity, flexibility and patient outcomes. While we do not believe that there can be a straightforward substitution of 'high tech' services in place of vital 'high touch' care and support, particularly in view of the value that service users and patients attach to the quality of the relationship they have with care staff who provide personal and intimate support, we are nonetheless convinced that there is enormous scope for developing models of 'hospital at home', and using telemonitoring to avoid hospitalisation and to offer safer discharges.
- Telemedicine and telecare solutions, as well as offering alternatives to residential care will enable people to remain at home safely for longer. The monitoring of vital signs and disease management may not appear directly to contribute to addressing the problem of delayed discharges, but the potential for indirect benefit is considerable, given that other beds can be freed up by using telemedicine for many acute episodic conditions (such as asthma, diabetes, and hypertension).
- Assistive technology ranges from social alarms to the transmission of digital images for diagnostic purposes. We use the term "telecare" to refer to these and similar systems.
- Tunstall Group Ltd, the leading UK provider of assistive telecare technology, told us it had developed multi-functional alarm systems that incorporated panic alarms and intruder alerts, and monitored an individual's activity to ensure quick responses to falls or extended immobility. The protection that this could offer was important in giving people confidence that they were safe at home. Tunstall are also developing more sophisticated patient monitoring systems using self-administered tests for chronic or suspected conditions. Mr Tony Rice, Chief Executive Officer for Tunstall, told us that it was developments in this area which had the greatest potential to make an impact on pressures in the health care system. He argued that harnessing such technology could help reduce the need for acute admissions, and accelerate discharge into the home or intermediate care where regular monitoring could be administered alongside clinical support.
- We were extremely impressed with the benefits Tunstall offered both to the patient and to the NHS. Tunstall estimated the costs of home monitoring were between two and six pounds per day with an additional £30-100 a day of clinical support. They also estimated that installing social alarms and telecare facilities in every household containing people aged over 65 in the UK would cost £1.2 billion, with an annual £750 million in running costs. Although these are significant amounts of money, the potential savings that may accrue from keeping patients out of acute care should not be ignored.
- We believe that telecare solutions have a major contribution to make as part of the strategy for developing alternatives to hospitalisation. This is an area in which health, social services, and other local authority services all have an interest, and where there is scope for pooling budgets to develop strategies. We recommend that the Department should establish a national strategy to promote the systematic development of telecare solutions as part of the spectrum of care at home, perhaps beginning with some properly audited pilots. Our visit to North America persuaded us that health care providers there were engaging much more fully with the potential for telecare, whereas UK telecare companies appeared frustrated with the lack of progress.
- Telecare has the potential not only to achieve cost savings, particularly in the management of acute conditions, but also to be a key component in the drive to allow people the choice of staying longer in their own homes. An additional benefit is that patient autonomy will be increased in that patients will play a more active role in managing their own conditions. We believe that the Government should examine ways of facilitating greater uptake of telecare solutions within both health and social care. In particular it is essential that primary care trusts have the expertise to engage creatively with these technologies, and that local authorities are aware of the possibilities afforded by technology in the running of 'care villages' (something our predecessor Committee witnessed as a reality in Denmark).
- In tracing the patient journey through the hospital we have indicated the wide range of factors that can contribute to delays. The complexity of the situation means that solutions are far from straightforward, and there is no 'quick fix' that can be applied.
- The fact that almost 30% of discharge delays can be attributed to waits for care home placement (either because of the lack of a suitable place for their needs, or because the home of choice has no vacancies), might suggest that the obvious solution would be the rapid development of further residential and nursing home capacity. We do not support this conclusion. While we accept that developing capacity in areas where there are shortages has a contribution to make within a wider strategy, we are concerned that too much effort is being put into developing 'more of the same', with insufficient attention being paid to focusing on providing the most appropriate care for people, and developing the necessary alternative service models to ensure that the right care, in the right place, at the right time, is available.
30 Ev 81. Back
31 Ev 289. Back
32 QQ 209-10. Back
33 Q209. Back
34 Q34. Back
35 The Single Assessment Process (SAP) for older people is being introduced across health and social care from April 2002, becoming fully operational by 2005. Its objective is to move towards a single assessment framework that will result in convergence of local assessment procedures, outputs and outcomes over time. In addressing a core set of 'domains' contained in the National Service Framework for Older People, the SAP will offer a person-centred approach that does not duplicate assessments and facilitates the sharing of information between a range of professional disciplines. Back
36 Q39. Back
37 Department of Health (2001), National Service Framework for Older People, para 4.28. Back
38 Ev 81. Back
39 Q297. Back
40 Q297. Back
41 A CT (Computed Tomography) scanner is an item of medical imaging equipment that uses x-rays to create images of slices through the body. Back
42 Ev 249 (Memorandum from Dr K Sritharan and Dr W Lynn). Back
43 The Management and Control of Hospital Acquired Infection, NAO, 2000, p.1. Back
44 Ev 265. Back
45 Q301. Back
46 Shaping the Future NHS: Long Term Planning for Hospitals and Related Services, DoH, 2000. Back
47 See A Bagust et al., British Medical Journal, 1999, vol. 319, pp. 155-58. Back
48 See The Role of the Private Sector in the NHS, First Report of the Health Committee (HC308, Session 2001-2), para 14. Back
49 Ev 286. Back
50 Ev 286. Back
51 Peterborough Hospital Trust: The Right Care in the Right Place and Building Care Capacity - Proposals for the Peterborough City Council Area. Back
52 Ev 40. Back
53 Ev 42-43. Back
54 Ev 49. Back
55 Q258. Back
56 Q357. Back
57 Q360. Back
58 Ev 79-80. Back
59 Ev 232. Back
60 Q613. Back
61 Q621. Back
62 Q621. Back
63 Q621. Back
64 Q621. Back
65 Q613. Back
66 Ev 53. Back
67 Q229. Back
68 Ev 152. Back
69 Ev 282. Back
70 Q353. Back
71 Ev 57. Back
72 Ev 57. Back
73 Q223. Back
74 Q353. Back
75 Ev 41. Back
76 Ev 41. Back
77 Ev 122. Back
78 Ev 129. Back
79 Ev 152. Back
80 Q602. Back
81 Q138. See Table 4.2, Laing & Buisson, Care of Elderly People, market survey (2001). Back
82 Official Report, 20 March 2002, Col 296. Back
83 Latest figures from Laing & Buisson indicate a further loss of 13,000 beds across all sectors during 2001. Care of Elderly People Market Survey (2002). Back
84 Ev 45. Back
85 Building Capacity and Partnership in Care, Department of Health, October 2001. Back
86 Our predecessor Committee, in 1993, noted that: "In oral evidence, Ministers were keen to persuade us that local authorities will be able to exercise purchasing power as bulk buyers to drive down prices". See Community Care: Funding from April 1992, Third Report of the Health Committee (HC 309, Session 1992-93), para 71. Back
87 Ev 249. Back
88 Q428. Back
89 Q428. Back
90 William Laing, Calculating Operating Costs for Care Homes, Joseph Rowntree Foundation, June 2002. Back
91 Q430; Ev 258 (Lancashire Care Association). Back
92 Ev 235. Back
93 Q155. Back
94 In the NHS Plan, the Government gave a commitment to make care from a registered nurse free for all, regardless of the setting in which it is delivered. See Health Service Circular HSC-2001-17. Back
95 Q535. Back
96 Q536. Back
97 Ev 139. Back
98 Ev 46. Back
99 Ev 120. Back
100 Ev 120. Back
101 Q260. Back
102 Ev 46. Back
103 Community Equipment Services: why should we care? The Disabled Living Centres Council, 1988. Back
104 Fully Equipped 2002, Assisting Independence, Audit Commission, 2002. Back
105 Q203, Q260; Ev 46. Back
106 Q263. Back
107 Ev 142. Back
108 Ev 142. Back
109 Telecare can be defined as: "the use of information and communication systems to give patients with or without their healthcare professional or informal carer access to information sources wherever they are located." The telecare process frequently takes place within patients' place of residence. The term telemedicine is used when referring to a number of applications of information and communication technology to medicine (the UK Telemedicine Information Society, www.tis.bl.uk). Back
110 Q499. Back
111 Q499. Back