Examination of Witnesses (Questions 186
WEDNESDAY 13 MARCH 2002
186. Can I welcome our witnesses to this session
of the Committee. Can I ask you each briefly to introduce yourselves
to the Committee, starting with you, Mrs Robinson?
(Mrs Robinson) I am Janice Robinson.
I am the Director of Health and Social Care for the Kings Fund.
(Ms Whitworth) My name is Diana Whitworth. I am Chief
Executive of Carers UK.
(Ms Harding) I am Tessa Harding. I am Head of Policy
at Help the Aged, but I am here as Chair of the SPAIN group which
is a coalition of voluntary organisations.
(Ms Herklots) I am Helena Herklots, Head of Policy
at Age Concern England.
187. Can I ask you to say a bit about SPAIN,
how it came into being and the background to it?
(Ms Harding) It stands for Social Policy Ageing Information
Network. It is a coalition of 30-plus voluntary organisations
of and for older people, focussing specifically on social care
188. Thank you. Can I also thank you for all
your written submissions which have been extremely helpful and
will be the basis for some of the questions that we want to ask.
Perhaps I could begin by saying that one of the issues I raised
with the government witnesses in the first session with the civil
servants from the Department was the actual cost of delayed discharges.
We as a Committee drew some figures out of our annual expenditure
survey which came up with a broad figure of a cost of around £720
million arising directly annually from delayed discharges. I am
looking at you, Mrs Robinson, as to whether you have any figures
from the Kings Fund that would either substantiate our estimates
or give an alternative figure. The reason I am asking is that
the Government actually did not have a figure. I was rather surprised
that they did not have any idea of the cost of this particular
problem. Do you have any thoughts about that at all?
(Mrs Robinson) It has been rather interesting in the
Kings Fund hearing your calculations, Chairman, because in our
national inquiry looking into care and support, when we were looking
at the whole gamut of provision for vulnerable people, particularly
elderly people, we noted that there was a huge mismatch in the
funding between the NHS and social care. We calculated that we
needed something like £700 million extra social care in the
financial year. That was not just to meet the delayed discharges
problem. We were ecstatic when we saw your calculation. We thought
we must be rather on the right track. Something in that order,
it would seem, is going to be important to try to close that gap
between the NHS and social care.
189. I think we may be misunderstanding each
other. Our estimate was based purely and simply on the annual
cost of an acute bed in a hospital times the number of people
blocking these beds over a year, so it is very much a back-of-a-fag-packet
calculation, if I can use that term in the Health Committee! It
is a back-of-an-envelope calculation of what we consider to be
the figure, but the Government did not have a figure. So broadly
you would concur that that is your own estimate on that?
(Mrs Robinson) Yes, I would. As I say, ours similarly
was on the back of a cigarette packet, in the sense that we were
looking at what the gap in funding is, recognising what was the
historically high record of amounts of funding in the NHS. I think
we would stress that we have not calculated what the cost of delayed
discharges would be, and nor is our figure designed solely to
meet that problem. I think we are talking about a whole range
of other provisions in social care that are needed, so it may
be in excess of that figure that you have actually mentioned.
190. Can I stick with you, Mrs Robinson, and
ask you another question, because in your evidence you said that
delayed discharges had been a problem for at least the last decade,
but that the numbers had risen dramatically over the last year.
From that point of view, it is interesting that it has risen in
such a way when there have been specific funds allocated to try
to deal with the problem. What do you see as the reasons why it
is a problem which has arisen in very recent times?
(Mrs Robinson) We focussed on two issues in our submission,
as you know, both of which are financialalthough of course
there are others, but I think they are the main onesthe
first being some of the financial problems afflicting the care
sector. You are all familiar with the extent to which care home
owners and indeed domiciliary care businesses are finding it difficult
to cope; some are quitting the business altogether, others are
refusing to take on local authority funded clients, because they
feel the fees are too low. That means that there is restricted
capacity for local authorities themselves to purchase and actually
to find the places. Local authorities themselves over just under
the last decade, since 1993, have been driving down the cost of
the price that they will pay for their own placements, and they
are now not in a position, because of their own financial difficulties,
to increase those prices. So we are having a real capacity problem
that has started to hit this year. An issue that is interesting
for us is that again in the Kings Fund inquiry we predicted a
crisis looming. We called it a looming care crisis, but actually
it started to hit at the end of last year, for those very reasons.
I think the second thing, leaving aside the care sector itself,
is that the development of alternatives, particularly in intermediate
care, has been disappointingly slow. While we have seen over the
last few years some excellent developments largely driven by short-term
winter pressures on money starting with the previous Administration
and going through the new Labour Government, we have not seen
the long-term funding coming through so that we can really plan
for those intermediate care developments on any great scale at
the moment. Indeed, some of it looks as though it is being diverted
into other purposes.
191. Can I ask youand other witnesses
may want to come in on this pointabout the way in which,
compared with not dissimilar European countries, we seem to have
invested very heavily in institutional forms of care for older
people, and the market has gone in a very big way for institutional
forms of care which are inevitably perhaps more expensive models
of care than some of the simpler solutions that other countries
have come up with. Do you concur with that? Our Committee went
two years ago to visit Denmark and saw a country there with, in
my view, a much more civilised system of community care and did
not have care that was too institutional, they seemed to manage
without it. Do we need to think much more radically about the
whole basis of provision in terms of long-term care for older
people particularly, to resolve some of the problems we are addressing
in this inquiry?
(Mrs Robinson) Yes, I would concur with that. On the
long-term care front, I do think that we need some forms of care
for some particular groups of people, particularly those with
advanced dementia and so forth (but for sure there are many other
models that we can invest in and which we are starting to see),
but it is still pretty much embryonic in this country. I think
that when you look at what has happened to intermediate care,
your point is well taken. There are all sorts of intermediate
care services which do not need to be based in a new building
with all the costs and rigidities that that implies, but there
is undoubtedly the caseand colleagues sitting behind me
are working on thisfor redevelopment in this country. There
are huge pressures, particularly among hospital staff, to invest
in beds, always to go for using the hospital, using the care homes,
rather than putting the money into rapid response teams who do
an excellent job. So it is not about one or the other, but actually
having a much better mix than we have at the moment.
192. Miss Harding, do you want to come in on
(Ms Harding) I just wanted to say that if you look
at the picture, we have rising numbers of very old people, people
in their eighties and nineties and beyond, in this country, and
that figure is rising quite steeply now. We actually have fewer
people receiving care in their own home. We have a greater number
of home care hours, but those are going to fewer people. We have
got fewer residential and nursing home places over the last few
years for a whole variety of reasons and we have got fewer hospital
beds. Those are down by around 4,000 between 1998-99 and 2000-01.
If you have got rising numbers of much older people and you are
reducing the number of services to provide support you are going
to get pressure on all the points of crisis. That is the accident
and emergency admissions to hospital and it is the problems around
delayed discharge because there is nowhere for people to go beyond
the hospital system. You are going to get more and more pressure
on the emergency side of the services and the most acute side
of the services.
193. Mrs Robinson, I was interested to hear
your comments about the problems of capacity with the closing
of some homes and the loss of some beds. Do you or the King's
Fund keep records of the number of beds lost?
(Mrs Robinson) No, we have not. Just in the course
of our inquiry last year we had a quick look at what was happening.
It was a snapshot though. We do not regularly and routinely monitor
developments in the care home sector.
194. Do any of the organisations before us keep
records of the number of beds lost plus on the other side the
number of beds gained by new homes being established, and whether
there is a net gain or a net loss in the number of beds for residential
care for the elderly in this country at the moment?
(Ms Herklots) One of the sources we use for that is
Laing & Buisson's work and certainly what comes forward to
us is that the issue is more complex. It is about local and regional
mismatches between demand and supply. In some areas there is clearly
a shortage of care homes and in others there may be an over-supply
and the problem is there is not a match between those two things.
The other issue, coming back to the Chairman's question
195. Can we stay on this a second. You mentioned
you use the Laing & Buisson figures so you will know from
those figures that if you took at random, say, the last five years
they show there is a significant overall fall in the number of
beds. Presumably you have noticed that. Do you accept that as
an accurate keeping of figures?
(Ms Herklots) Laing & Buisson is the best that
we have got on the figures. It seems the best.
196. I would certainly agree with you. Could
you then explainand you may not be able to because it is
not your responsibility but you may be able to throw some light
on itthe confusion I have when every time you tell a Government
Minister about the Laing & Buisson figures and the overall
fall in the number of beds over, say, the last five-year period,
they say that is not a case, there has been an increase in the
number of overall beds. That is a significant difference given
the number of beds lost that the Laing & Buisson figures show.
Have you done any research to clarify who is accurate, Laing &
Buisson or the Government?
(Ms Herklots) No, we have not.
(Mrs Robinson) It would be interesting to know which
sorts of beds everybody is counting. I know in the past when any
government of any hue has talked about beds they have put together
a whole of range of things, including what may be step-down intermediate
care facilities in hospitals which are not part of the acute hospital
set-up. It may be that they are both speaking the truth but we
need to know who is counting what.
Mr Burns: I understand that and that is probably
the mistake I made at the beginning because I assumed the Government
would be working on the basis of beds for care for the elderly.
When you then table questions to them specifying that it is just
residential nursing beds for the elderly in homes, you still get,
for some odd reasonmaybe it is not an odd reason, it depends
on who is writing back and who is from the Governmenta
clarion call that beds are rising in total numbers.
197. Can I add a cautionary note as somebody
who would see the decline in care beds as a possible marker of
success of alternative provision. We need to look at this in the
whole. Presumably we do not have any mechanism whereby we can
establish if there has been a fall-off in the number of care beds
and nursing home beds if there has been a similar take-up of investment
in alternatives within the community. I am sure that most of us
would prefer to see investment in the community preventing people
needing nursing care beds in the first place.
(Ms Herklots) The problem is that the focus has been
on just one element of the care market, if you like. Another important
aspect of this is provision of things like extra care sheltered
housing, which offer care and good accommodation and can be one
alternative to residential care. What we are missing at the moment
is a mix of different options for older people in the locality
that they want. Too often the choice is between a care home or
not enough care at home and there needs to be the development
of a lot of different options in between those two things.
198. Can I ask you an introductory very vast
question. I am looking for one-word answers and trying to put
them into topics. The question is what do you see as being the
key causes of delayed discharges? The way I would like to tackle
that is in four stages: first of all, before anybody gets into
hospital; secondly, when they are in hospital getting over the
inefficiencies to speed the hospital progress; thirdly, the delay
in coming to the discharge, whether it is by the consultant or
the multi-agency team; and fourthly, the delay of implementing
the decision. Is it fair to just list them under those four headings?
Who would like to go firstbefore getting to hospital, avoiding
(Ms Whitworth) It is interesting that you should ask
me to answer the question first, Chairman. I think one of the
issues we would say is that carers' experience is that they tell
us about the problems of people being discharged too soon, so
it is quite the other side of the coin because if there is a problem
that they might be seen as part of the source of the delay, it
is for a number of reasons. It is interesting that you talk about
the period before hospital and the processes in hospital. One
of the problems is that very often carers have had previous very
poor experience of hospital discharge processes. They may already
be on a roundabout of people being discharged and readmitted,
so they are very concerned about that. They also have the view
that they are not properly prepared at home to be able to look
after somebody who is discharged. I think that goes back to the
previous discussion which is about the lack of resources that
are available in the way of domiciliary care for support in the
home. Thirdly, I think the issue, of course, is about lack of
residential home placements for people. Perhaps there is also
the major issue which is that a carer will have a view on whether
somebody is well enough to be discharged, and we do hear frequent
stories of people who have been discharged when they are clearly
unwell and then are subsequently readmitted or even die.
199. Thank you. Mrs Robinson?
(Mrs Robinson) In a way I do not want to answer the
question in the way you put it. Will you allow me to do it slightly
differently, because I think it is important to look at what is
happening with individual doctors, nurses, social workers and
whoever are working with individuals, but we need to look at what
I am calling "structural" pressures on those people
which influence their behaviour. I therefore come down to two
things again, one which is money, which is why everybody squabbles,
people do not squabble very much when it is not an issue and,
two, the political pressures on the NHS at the moment to get people
through those beds very, very quickly, to get the waiting lists
down is probably, and very possibly, encouraging some Health Service
staff to move rather more quickly than they might otherwise do.
I think the political pressures are quite intense at the moment.