Oral evidence: Discharging older people from acute hospitals HC 76

Oral evidence, 6 June 2016.

Witnesses

Simon Stevens, Chief Executive, NHS England, Dr Kathy McLean, Executive Medical Director, NHS Improvement, Sarah Mitchell, Director, Social Care Improvement, Local Government Association, and Jon Rouse, Director General, Social Care, Local Government and Care Partnerships, Department of Health, gave evidence.

Chair

Welcome. I am sorry that we are starting later than usual. We had a very useful previous session. It is a shame that you weren’t here to listen to it, Mr Stevens, because it was really instructive; I think others who were in the room were able to hear that. For those who may be tuning in or who were not in the room earlier, I repeat that we are here today to take evidence on the basis of the National Audit Office’s Report, “Discharging older patients from hospital”. In the last couple of years we have seen delays for older patients in hospitals rise to record levels. In our pre-panel, we heard from what we might describe—I think I speak for the Committee—as the exemplar model: David Evans, chief executive of Northumbria Healthcare NHS Foundation Trust, where they have 0% of overstaying older people, which is the model. On our second panel is Dr Kathy McLean, executive medical director of NHS Improvement. Welcome, Dr McLean. I think this is your first outing in front of our Committee.

Dr Kathy McLean

Yes.

Chair

Simon Stevens, a regular visitor to us, is chief executive of NHS England—I am sure you look forward to every time, Mr Stevens. Jon Rouse is director general of social care, local government and care partnerships—I think your title gets longer every time you come. Sarah Mitchell is the director of social care improvement at the Local Government Association. We felt that it was important to get the balance, as we have heard from our first panel about the interaction between social care and health. Our hashtag today, for anyone who is just tuning in, is #olderpeople. I am going to transfer straight to Anne-Marie Trevelyan, to kick off.

Mrs Trevelyan

We have had a very interesting pre-panel meeting. Mr Stevens, you will know that I have been very closely involved with the Northumbria developments over the past 10 or 15 years. It is therefore really depressing to read in the Report that while we have cracked it in Northumbria, in terms of joining up all the various parts of the medical frameworks that are needed to look after a patient from the moment they come into A&E to the moment they go out again into either their home or some sort of residential support, across the country that really is not happening at all. I was not here at the time, but this was looked at some 13 years ago and it was deemed a Government priority to sort this out, according to the recommendations. It has not gone in that direction. We are looking at nearly £1 billion, which could be spent a whole lot better in any part of this framework, being poured down the drain. The first question is this: why has there not been the planning that must have been needed? We knew that the growth in the over-65s was coming—that was not news to anyone—and that there would be this predictable rise in A&E admissions. Where has the failure been in planning for and preventing that increase over the past 13 years?

Simon Stevens

An open question. Perhaps I can begin by slightly taking issue with the premise of the question, and indeed with something that you said, Chair. Actually, the late discharge of older patients from hospital is not at a record high; it is almost certainly better than it was in 2003, when the NAO last reported. Indeed, the NAO’s 2003 Report recorded that there were 4,100 older people awaiting discharge in hospital at that time. I think the definition used then was people over 75 rather than over 65, which has been used in this Report. The situation is in fact substantially better than it was then, both in absolute numbers and in terms of your chance of being delayed in hospital, because obviously we have many more older people using the national health service now than we did then. That said, the fact is that we clearly can do better. I do not think that the figure of nearly £1 billion that you talked about is right, but that does not detract from the fact that there are parts of the country where these arrangements are working well and there are parts where they are not. Although only 3.5% of bed days overall are affected by the definition of delayed discharges, that is 3.5% too many, so it is not good for older people. Although, I do think that it is worth noting that the NAO Report itself says: “we heard from a broad range of stakeholders that the main driver of day-to-day decisions on when to discharge patients from hospital remains patient care and safety, rather than financial considerations.” I am sure that we would all agree that that is right.

Chair

I need to bring in the NAO on this issue of the record levels. Could you explain the figures so that we are all clear what we are talking about?

Ashley McDougall

We would have been very happy to give the 2003/2016 comparisons, but the numbers were not available to us, so we could not compare. We were not actually able to say whether it was better then or now from the numbers that were available.

Stephen Phillips

And what about the 3.5% of total beds that Mr Stevens talks about that are essentially blocked by those who are awaiting discharge?

Ashley McDougall

I think that refers to the delayed transfers. The 2.7 million bed days—we are probably heading for about 8% or 9% of total bed days. That would be my understanding.[1]

Chair

Mr Rouse, it looks like you can cast light on this.

Jon Rouse

I just question where the higher figure comes from—the 8% to 9%.

Ashley McDougall

When multiplying the delayed transfers figure, which is the 3% I think Mr Stevens is referring to—

Chair

We don’t want to spend forever on this, but we do need to be clear about what we’re talking about.

Simon Stevens

The point is, there is not a basis for saying it is the worst it has ever been. If anything, it probably isn’t, but the fact is there is still a lot more we can do. That is where the concrete conversation needs to focus, and that is what patients want.

David Mowat

Just for clarity, you said that the £1 billion figure was wrong, or was not right. What in your view is the figure?

Simon Stevens

Well, it is £820 million in the NAO Report, as you know, and that has various assumptions behind it. First, there is an offset of £180 million, which the NAO says would be the cost of providing care in alternative settings, producing a net number of £640 million. That number is based on a grossing up by 2.7 of the actual day’s delay that hospitals themselves report, which is 1.16 million. Multiply that by 2.7 and that gives you a bigger number, and then multiply that by £303 a day, which I am not sure is indeed the right marginal cost for an in-patient day—

Chair

Sorry, that is an NHS England figure.

Simon Stevens

No—

Chair

What is the right figure, then?

David Mowat

I asked you what the number should be. We will just take that number.

Simon Stevens

I think the bookends would be net zero to net £640 million. Net zero would be if you assumed that you didn’t gross up by 2.7%, you just took the recorded delayed discharges; you used £200 a day as the marginal cost, rather than the reference cost trim point; and you took some allowance for the extra costs of primary care. Those are the bookends.

Chair

Sorry, can I—

David Mowat

Sorry, Chair, if I could just finish this. If you are managing the issue, what number would you take as the target that you have got in your organisation to go after in this regard?

Chair

You must be planning it financially.

Simon Stevens

If you think that somewhere between nought and £640 million is quite a range, then let’s call it £300 million to £400 million as a central estimate. It could be north of that. It is worth going at, there is absolutely no doubt about that, but the context for all this is that the NHS has been incredibly efficient over two decades in the use of emergency in-patient bed days. What has actually happened is that we have accommodated a 17% increase in the number of­—

Chair

You have answered Mr Mowat’s question about the figure. I want to bring in the NAO here. We know that there was a discussion about how to guesstimate or estimate the cost to the taxpayer—how the NAO do their figures. I am not taking into account the personal costs to individuals of this. The NAO had trouble getting the data. I am going to ask Ashley McDougall to explain very briefly the process that the NAO went through so that everyone is clear where those figures in the Report came from. It is very unhelpful to have an argument about those figures—even if they are acknowledged not be perfect by the NAO—in the opening five minutes of the hearing.

Ashley McDougall

We went to NHS trusts. We had two starting points. The first one was the delayed transfer figure, which are returns collected by NHS England. That takes you to about 1.1 million bed days. The second figure was an extrapolation. We had 27 trusts in our sample. Trusts collect lists of patients they say are medically fit for discharge and/or no longer benefiting—I think that is the phrase in the Report—from acute care. The 2.7 multiple that Mr Stevens talks about came from the figures of the people who were not counted in the delayed transfer figure but were there and not benefiting from acute care. We then multiplied that by the £303. We certainly discussed with the Department and NHS England whether there was a better figure for using for that. These figures are all national estimates. I think with the figure of £303, what tipped it for us in the end, to an imperfect estimate, was that £303 is the NHS’s standard number that it uses to count these figures. You may be familiar with the Carter review. The Carter review came up with a figure of about £900 million for the delayed transfer gross costs, and we are at £820 million—I think they are broadly in that field.

Chair

Mr Stevens, we have heard from both sides, but there shouldn’t be sides on this. This is an agreed Report.

Simon Stevens

This wasn’t agreed.

Chair

The NAO is supposed to be here in silent support while we deal with their excellent work, not having an argument about this.

Simon Stevens

Their work is excellent.

Chair

Can we agree that we agree the Report? We know those figures have come with caveats. We know that as a Committee. We don’t need to hear every detail about those caveats.

Simon Stevens

Well, the detail matters if we are trying to get a true estimate. The NAO have entirely legitimately laid out an appendix to how they have come up with—in your word—a guesstimate.

Chair

We’ve got the Carter figure. We have got the NAO figure, with its caveats. We have got your bookends, as you put it. We have now got you down to £300 million to £400 million.

Simon Stevens

That would be the central estimate between those two.

Chair

So you are taking not quite a median, but near enough. We will leave that there and go back to Anne-Marie Trevelyan to carry on with the questions.

Mrs Trevelyan

Whatever the quantitative number, the qualitative issue is real: we have very serious bed blocking issues because of the breakdown. So I would turn it on its head and say that, with the resilience groups now set up and spread across the country, it would be interesting to know the views of all the panel on whether that is helping in real terms. There is a difference in views, certainly in the NAO Report, between those on the social care side and those on the acute hospital side of whether that relationship is actually helping to reduce the blocking and helping the comfortable and effective throughput of patients.

Simon Stevens

As you say—I agree with you—it is a pretty mixed experience across the country, and I think that is what comes out of the NAO’s survey. These so-called SRGs were essentially a workaround to get people sitting around a table clocking the fact that the impact of one organisation’s behaviour spills over into how patients in other parts of the care system experience their continuity of care. In some places, they have worked reasonably well, in other cases clearly not. There is a limit to what one can and cannot mandate, sitting within a mile or two of this building, in terms of the relationships and the quality of these conversations, but there are some other changes in terms of processes inside hospitals, the relationships between hospitals and community health services and the relationship between the NHS and social care. I think we have got an increasingly clear picture what the gold standard looks like, and we will be using that as a criterion to judge whether people are able to graduate from what they currently experience as quite an onerous set of oversights around the Better Care Fund. We intend to lay out, “If you are doing these kinds of thing, you potentially get to graduate from the Better Care Fund and all its reporting requirements.” That is quite a strong incentive, I think, in various parts of the system, but there are other things we are doing as well, and we can certainly talk about those.

Mrs Trevelyan

So what does that gold standard look like?

Simon Stevens

To start with the discharge planning process inside the hospital, we know that beginning that process early on in a patient’s stay is very important. We know that it makes sense to try to discharge—this is the goal that we have set—at least 35% of patients by midday. That is not happening uniformly across the country. Seven-day discharge arrangements inside hospitals are important too. We know that hospitals’ ability to discharge patients safely and appropriately to home on a weekend is diminished. In terms of the hand-offs between hospitals and community health services, there is a disconnect in some places on the incentives and availability of those community services. In terms of the interaction with social care, as the NAO Report rightly points out, many care homes do not at the moment have response time standards as part of the contracts that have been set with local authorities. That is an important part of making this a slick system as well. Then there are a set of other things around so-called discharge to assess, so that when a patient is ready to leave hospital, they can have an assessment of what sort of follow-on care they need when they are back at home or in a nursing home or intermediate care bed. There is a whole series of things that we have published with the LGA, ADASS and a number of other bodies about what those standards should look like.

Stephen Phillips

What you have just described, Mr Stevens, as the solution, if I can put it in those terms, is a series of process changes that need to be made, as I understand it. If you had been here for the last session, you would have heard my questions to Mr Evans from Northumbria about how they have got it right, with 0% delayed transfer cases. I asked him whether it was about structures or processes. His answer, as I understood it, was that if you put the right structures in place, the processes will follow. My question to you and to the rest of the panel who are responsible for it is this: are the right structures currently in place to deal with this problem, which on any view is costing the NHS in England several hundred million pounds a year?

Simon Stevens

I am a huge respecter of the work that has been done in Northumberland. That is, obviously, a series of relationships built over many years. It is not something that you can just conjure up overnight. However, I doubt that the Northumbrian model is replicable in every part of the country, and I certainly don’t think that the de facto nationalisation of social care by the NHS is a model that would work in every town, city and county across the country. So I think we are deliberately going to have different approaches. Jon Rouse is here—

John Pugh

Why wouldn’t it? Why wouldn’t the Northumbria model work in other places?

Simon Stevens

Versions of the Northumbria model are in place. One of the differences is that the structure of provision of care and public financing versus self-pay, and so on, is quite different in the north-east of England from how it is in many other parts of the rest of the country. So there is a mixed funding model in social care and there is a mixed provision model in social care.

John Pugh

So for absolute clarity, are you saying it wouldn’t work in other places because the inherent structures upon which you are building in other places are actually too different from Northumbria? Is that what you are saying?

Simon Stevens

The starting conditions are clearly different, yes. I don’t know if John—

Chair

I don’t know if Sarah Mitchell might have something to say about that from the social services perspective.

Sarah Mitchell

I think there are very different sets of circumstances that influence whether the model would work in different places. The difference in terms of the number of self-funders in one local authority will influence that—there are some places where there are 85% of the older persons funding themselves, and in some parts of the country that’s very different. In response to the structure versus process point—I think someone did mention this—the important bit about leadership is also linked to the system resilience groups. We have been round a lot of systems resilience groups, and where the leadership is strong and all the partners are brought together and they have a shared vision, a shared ambition, and a plan—it sounds a little bit managementy, but it does work. We have seen it work where places are really not working well together; it has been about facing that up, putting a mirror to them, and saying to some places, “If an older person who is a patient in the hospital walked into this meeting now, would they feel very confident about your ability to solve the problems?” That can shift places, and we have seen places shift.

Chair

Can you give an example?

Sarah Mitchell

Oxfordshire would be a good example of that, and Cambridgeshire, actually, where really complex and difficult relationships shifted. Now, they are not at the lowest end of the delayed transfers, but they are certainly on the way, and, most importantly, the relationships have changed. We have really seen that it does take time to change this; and the model that we have been working with, with NHSI and NHSE and DH, is around looking at what really are the best things out of Northumbria, and turning them into a set of things that you ought to be doing, like early discharge, multidisciplinary working, all of those things. It is about listening to people, as Independent Age pointed out, and you can start to apply those things in different places. Just very quickly, on the SRG issue, I think there needs to be a relationship with the health and wellbeing board, so that this is really put together for a local area; and the voluntary sector and the care providers need to be round the table as well. There is no point in us saying, “Oh, you know, the care providers don’t respond”, or “We haven’t got the workforce,” if they are not part of finding the solution together.

Jon Rouse

On this particular question of models, I think we have a growing bias or interest in what are called local care organisations, which is providers coming together; and Northumberland is not the only example. We have examples now in Salford and Torbay, and there are a number of others around the country. I think we will see those grow in number. I think what we have got to avoid is believing that there is one top-down, prescribed approach for every geography. That is partly to do with the differences in starting position in terms of the markets, but it is also to do with institutional strength. Frankly, there are some health providers that are not in good enough shape to take on those social care responsibilities at this time. So we have to have a multi-speed approach if we are going to make those sorts of structural changes.

Nigel Mills

Are you thinking about it, though, Mr Rouse? When you say “not at this time”, what I hear is “We’d quite like to do it, but we don’t think we can.” Is that—

Jon Rouse

I think I also said that we don’t want a single, top-down, prescribed approach.

Chair

So could it be part of a devolution model?

Jon Rouse

It certainly can, and in Greater Manchester, which is obviously where I am heading personally next, there is an ambition in each of those local areas to move towards some form of local care organisation to integrate those services.

John Pugh

And would you say the optimum condition would be one where there was a fully integrated body delivering them? You talked about collaboration in Oxfordshire and Cambridgeshire, and these things are to some extent fortuitous. People may get round the health and wellbeing board and all agree things, but they may equally fall apart. Would you go on record and say that the optimum scenario is one where you have a Torbay, Salford or Northumbria-type model?

Simon Stevens

It depends a bit, doesn’t it, on what we mean by fully integrated? There are, what, 400,000 care home beds? We are presumably not talking about nationalising those to go alongside the number of hospital beds.

Chair

Social services—social workers.

Simon Stevens

They and the domiciliary care providers, which are for the most part in the private sector, are the people delivering this care.

Stephen Phillips

Let me explain the problem that I have with all of this. You are the chief executive of NHS England, Mr Stevens. Mr Rouse, the Department is responsible for the NHS in England. Yet we have these very wide regional variations in the percentage of patients who are not discharged on time and who essentially end up blocking beds, which costs acute trusts money. Don’t you regard this as a problem that you actually need to grapple with, because it’s something of a national disgrace that there is this discrepancy across the country? It does not just cost the NHS money. Remember—I think this is in the NAO Report—there is 5% muscle wastage for an old person who is stuck in a bed that they should not be in. So it’s important for patients as well; it is not just about the several hundred million pounds that the taxpayer is losing. So why aren’t you sighted on this—

Simon Stevens

We are.

Stephen Phillips

—and bearing down on it much harder than appears to be the position from the answers you are giving?

Chair

Mr Stevens, you say you are, but just to add to that, as Mr Bacon, who has an elephantine memory of his many years on the Committee—thankfully—has said, 13 years ago this Committee, probably in this very room, discussed this very issue on the back of another NAO Report and the system was not working well then. So, Mr Rouse first of all and then Mr Stevens, what have you got to say to what Mr Phillips has raised?

Jon Rouse

First of all, you are right that there is unacceptable variation in performance.

Stephen Phillips

Unacceptable variation—your words.

Jon Rouse

Yes. I am very happy to make that point very clearly. But first of all, can we recognise that, certainly on the social care side, there are quite a lot of local authorities that are actually doing pretty well in terms of numbers of delays? In fact, there are 58 authorities—that’s 38%[2]; all upper-tier authorities—whose current levels of delays are below the historic average low position from two years ago today. It’s not that Northumberland is the sole celestial star out there. There are actually a lot of local authorities that are doing pretty well on this. The problem is at the other end of the spectrum: we have 22 authorities that are doing at least three times as badly as that group of 65 authorities in terms of their delay rate. Up to this point, over the last two years, working with those authorities, and others like Oxfordshire and Cambridgeshire that have improved, we have taken the approach, working with the LGA and ADASS, of putting in place peer support mechanisms. We have gone into those places. We have worked with those systems, using the ECIP mechanism, which is the NHS-based mechanism; using our Helping People Home Team, which we set up jointly with the LGA; and using the LGA’s own peer support programmes. In some of those areas, that has made a difference and those rates have come down, but in other areas, they are still very much stuck, so the question that we are now grappling with—this very much includes Ministers as well—is what we do next with those localities, because you’re right: we can’t have those levels of delays continuing to go up in those outlier authorities.

Stephen Phillips

Of which Lincolnshire is one. I will come to Mr Stevens in a minute on this question, but answer me this, because we’ll have you back at some point and hold you to account on it: when is everybody going to be down to Northumbria’s 0% delayed transfers of care?

Jon Rouse

I can’t give you that answer.

Stephen Phillips

Well, do your best.

Jon Rouse

I can’t. I can’t give you that answer.

Stephen Phillips

Well, are you going to be back here in two and a half years’ time telling me that it is as bad in those acute trusts that are doing very badly as it is today, or is some difference going to have been made?

Jon Rouse

On a personal level, I will be in Greater Manchester accounting for what we have done for the Greater Manchester authorities, and three of those are among the 22 authorities that I have named. But on the substantial point, what we have to do first is turn around the upward trend. From 2010 to 2013, we brought social care delays down to the lowest level they have ever been at; it is since then, and particularly since the summer of 2014, that they have started to go up significantly. So the first thing we have to do is turn around that trend line and start making that journey back down to where we had reached in the summer of 2013.

Chair

On that point, do you think the NHS is able—at some point we’ll bring Dr McLean in on this—to improve fast enough? We are bandying these figures around, but the total number of people, because of the number of people going through the system, is going up. The NHS is just not keeping pace with that change. Do you not agree, Jon Rouse, with that analysis? It is not keeping pace with the numbers going through the system.

Simon Stevens

I actually do not agree with that analysis, and I will tell you why. Over the last 17 years, we have had a 52% increase in the number of emergency hospital admissions, and we have had no increase in the number of emergency beds we have used to support those admissions. That is proof that the NHS is actually getting slicker at its discharge processes, reducing length of stay and using our acute beds more efficiently. In fact, we have a lower number of acute in-patient beds than any of our industrialised country comparators, with the exception of Sweden, which again illustrates that overall the NHS does a very good job on this point. Had we not had that efficiency over the last 17 years, we would have had to build another 39 hospitals just to accommodate that 52% increase in emergency admissions. We did not do that.

Chair

I want to bring Anne-Marie Trevelyan back in, and Kathy McLean is next, but I also want to ask you this question very directly, Simon Stevens, as you have the floor now: when you hired Mr David Evans’s predecessor, Jim Mackey, as the chief executive of NHS Improvement, did you not give him some sort of mandate to replicate across the UK some of the excellent work done in this and other areas in Northumbria? It does not sound like it, from what you are saying.

Simon Stevens

Jim was actually hired by the board of NHS Improvement, but yes, one of the—

Chair

I am sure they asked you if you liked the idea.

Simon Stevens

One of the clear attractions of examples like Northumbria and some of the other vanguards we have in place is that they are demonstrating what can be done and the impact it is having. I wonder if I can introduce a slightly—you might think this is strange—pessimistic note of conversation, which is that I think we are going to be battling some very substantial headwinds over the next two, three and four years. So the honest answer to Mr Phillips, which I know you will not like, is that I don’t think we can guarantee that the number will be anything like zero over the next three, four or five years, because there are real pressures building in social care, as you know, and those pressures spill over into the NHS.

Chair

Sorry, but there are also pressures in the NHS; let’s be clear.

Simon Stevens

Indeed there are.

Chair

A shortage of junior doctors and other mid-ranking professionals.

Simon Stevens

That’s right. I will make the LGA’s case for them, and they can make my case for me.

Chair

I am going to go back to Anne-Marie Trevelyan and then to Nigel Mills, but Dr McLean, on NHS Improvement, it is in your bag to make sure that the best practice is replicated. Can you do it? Do you think you can set a time for when you can do it by?

Dr Kathy McLean

First of all, can I say that this is a very important issue? I was a geriatrician before I became a medical director, so I have personal experience of this kind of issue. Indeed, it is not new, as you point out. We welcome the Report. The SRGs are very much about the whole system working together, and we know that. The figures from the Report show that it is not a single part of the system that is primarily at fault. This is a system thing that has to be solved. There is going to be, under the A&E improvement plan for 2016-17 jointly led by NHS England and NHS Improvement, a review of and a refocus of SRGs. That plays to the point about chief execs thinking SRGs were not as effective as other people thought, so we think they will welcome that. On the business of why we do not roll out Northumbria’s examples to everywhere, there are a number of vanguard pilots going on that will probably give us some information about different areas. If I can turn to what we have been doing as NHS Improvement and your point about it being our job to spread the good practice, we recognised that this was a problem a while ago. We set up, as a starting point, a quality improvement programme based at Leeds teaching hospital. Through that, using quality improvement techniques, they managed to reduce by 700 bed days the occupancy and by 30% the delays to discharge. That is being rolled out as a pilot across the north of England, and a range of organisations are doing that. Our plan is to take the good practice from there and use it across the whole of the acute sector and beyond. That is our model—peer-to-peer organisations helping each other, with good leadership to bring about that improvement, and the sustainability hopefully will be around using quality improvement techniques and methodologies.

Karin Smyth

So are the system resilience groups accountable to you, Dr McLean?

Dr Kathy McLean

No, I think they are technically accountable to—each party that comes to the table is jointly and severally.

Karin Smyth

So who is accountable in each geographical patch?

Dr Kathy McLean

Each geographical patch will have a chair and a leader for each of those.

Karin Smyth

So the chair is accountable to NHS England?

Simon Stevens

Yes, but the director of social services who is a member of that committee is not accountable to NHS England. These are different statutory organisations. They have got to get together and figure it out locally with our support and with a nudge—sometimes more than a nudge. That is working in some places—it is not working everywhere—but let us not kid ourselves: even with the best relationships, restructures and good processes at the margin, a set of impending pressures is still headed our way that will make the impact on patients and the national health service a concern over the next three or four years.

Karin Smyth

Agreed. But in terms of Mr Phillips’s earlier question about whether Mr Rouse is busy in Manchester or coming back here, who would come back here to be accountable for whether those resilience groups are successful or not?

Simon Stevens

They are a means to an end. They are a meeting. They are a committee. They are not a structure. They are not a statutory entity. Kathy has responsibility for ensuring the spread of best practice on hospital discharges. NHS England has responsibility for ensuring that the different parts of the health service are working well together with local authorities.

Chair

Okay, but in a locality—

Simon Stevens

That is just the reality isn’t it? Local authorities run social care—

Chair

Mr Stevens, we are about to see devolution. We are already seeing public health in local authorities and we are seeing other joint models; it is not new. Ms Smyth has asked a simple question: who is going to be accountable? You have given us all the structures, but in those local areas, if I had a relative in hospital who was not being discharged, whom would I go to to raise concerns about that?

Simon Stevens

Well, quite frankly, it is a category mistake to say that there is a single person or organisation that is responsible—

Chair

Isn’t that the whole problem?

Mr Bacon

It is a very good answer; it is a very illuminating answer. Do you think we have got a systemic problem, Mr Stevens?

Simon Stevens

Yes I think we have. We have got fragmentation in our care system. I do—

Mr Bacon

Thank you—yes is good enough. If we have got a systemic problem, we plainly need a systemic solution. Yes?

Simon Stevens

Well, if by that you mean a new piece of legislation or a statutory reorganisation, no I don’t agree with that.

Mr Bacon

I mean a systemic solution to a systemic problem.

Simon Stevens

The proposition in the five-year forward view—

Mr Bacon

I did not define what the systemic solution was. I am just asking whether you think that since we have agreed we have got a systemic problem, we need a systemic solution.

Simon Stevens

Yes, I think that what we need is what we have described as triple integration between primary and specialist care, between physical and mental health services and between health and social care. The form that the triple integration takes will vary in different parts of the country. That is what the whole of the five year forward view agenda is about: getting those different models going.

Mr Bacon

I accept that there has been efficiency improvement; you have made some good points about that. To be honest, I do not get a sense listening to all of you—you are all highly intelligent people who have been grappling with this problem for a long time—that you have done what Mr Evans identified as the problem, which is to grasp the nettle. Sometimes it is useful to measure things in second world wars. This Report that we took evidence on—it actually came out in 2003—is more than two second world wars ago in terms of time. If you were going to solve the problem doing what you have been doing, you would have solved it by now. The reason you have not solved the problem yet, doing what you have been doing, is that what you have been doing is the wrong thing. That is what is wrong. Mr Stevens you mentioned, and it is in paragraph 1 of the Report, that there are “4,100 older patients on any given day”. That was 13 years ago. The National Audit Office mentioned that there two different figures: there is the 1.15 million—

Mr McDougall

8,500 is the figure we are using for our—

Mr Bacon

Right. Let me finish my question. You mentioned a whole series of people that are not being counted. Am I right that that is the difference between the 1.15 million bed days figure and the 2.7 million figure?

Mr McDougall

Yes.

Mr Bacon

If you take the difference between those two figures, that alone is 1.55 million, and if you divide that by 365, curiously enough it is 4,200. By itself, the bit that you are not counting is more than the number from 13 years ago. I’m not saying that you’re not trying but it certainly seems to me—I do not want to speak for others—that you must be missing something, otherwise you would have made more progress, notwithstanding all the different pressures. We have all had stories in our constituencies. My late father-in-law was in the Norfolk and Norwich University hospital for four days longer than he should have been. After bellowing at everyone at four days, because he was reasonably bloody-minded and articulate, he phoned a taxi and discharged himself. But not all patients will do that, and it is costing a great deal of money at a time when you do not have money spare. You need a qualitative step change, don’t you?

Simon Stevens

In many parts of the country, yes. But that step change is not exclusively in the gift of the national health service locally.

Mr Bacon

Fair enough.

Sarah Mitchell

I think that one of the reasons that there has been difficulty in recent years has been the issue about the absorption of the savings that local government had to make. We are estimating it as £5 billion since 2010, which is exactly the time from which delayed discharges have increased and where the pressures have been for domiciliary care providers.[3] There are places that are being really quite innovative about how they address that. They are starting to pay travel time. Calderdale, for example, pays for the careworker to be retained while the person goes into hospital, but it is on a shared risk element. Everybody knows that that person will go into hospital and come out as quickly as possible, and they are really working together on the ground to make that happen.

Mr Bacon

Mrs Mitchell, plainly the Northumbria model will not be equally applicable in all respects and all places. Anyone can understand that. How many other places in the country are there where the NHS trusts run adult social services in the way that Mr Evans described?

Sarah Mitchell

I don’t know the actual figure but there are lots of examples. They are different according to the local circumstances.

Mr Bacon

I’m sorry, you say that there are lots of examples but you do not know the actual figure. Do you mean where, essentially, the NHS trust runs the adult social services under a contract in the way that Mr Evans described?

Sarah Mitchell

There are some examples.

Mr Bacon

How many?

Chair

Single figures or—

Jon Rouse

Single figures. It is probably going to grow up to the 20 mark through ones that are already in preparation.

Mr Bacon

How many—Mr Bodmer would have known this—directors of adult social services are there? How many social services departments are there?

Sarah Mitchell

152.

Mr Bacon

And you reckon that, probably, five to 10 of those, or a small number—perhaps you could write to us with the exact figures—are as Mr Evans described.

Sarah Mitchell

In variations of that. There are some places where mental health trusts have been combined for quite some time. Some of those have been really successful and some of those—and they are where the social care staff have seconded into the mental health trust—have not worked so well and they are coming out of those arrangements.

Mr Bacon

Could you send the Committee a note listing all the adult social services departments in the country and, in the second column, who runs them?

Sarah Mitchell

Yes.

Mr Bacon

Thank you. Perhaps you might combine for that.

Mrs Trevelyan

There is a clearly a balance of responsibility here, and you can defend each other or not, and that is fine. But, within the hospital framework, a variety of issues such as unnecessary admission and failure to have enough geriatricians—we have snaffled one away from the front line—are set out well in the Report. How is the NHS tackling those front-line things so as to reduce admissions? In a lot of cases, there is not necessarily the need. We have 5% to 8% of admissions on medication problems, which could have been dealt with at the door and maybe did not actually need to come into the hospital at all. How are you addressing and dealing with that front-line part of the problem?

Dr Kathy McLean

So, this is obviously a big focus for us. There is something called ECIP—the emergency care improvement programme—which started in the back end of 2015. It initially worked with 27 trusts and foundation trusts. ECIP has clinical leadership and works right across the whole pathway from the front door of the hospitals. It tends not to work as much outside the hospitals but it has done a lot to look at the standardisation of the processes, the clinical leadership within emergency departments and so on. That continues as work, and will roll out further and be part of the overall plan for A&Es.

Mrs Trevelyan

So, specifically regarding the older people who turn up at the A&E door, what work is going on? Where are you seeing it working and where do you need to do more to actually stop those admissions in the first place that do not need to be coming through the system?

Dr Kathy McLean

Where they have good systems of supported discharge in place right from the front door, where they are able to identify good support in terms of seven-day services, physios, OTs and so on, that tends to work better, but I cannot particularly say where is doing that, from the ECIP point of view. A report was published by Monitor, pre-NHS Improvement, on moving care closer to home, and there were quite a lot of good examples. For example, Airedale has telemedicine in nursing homes and so on, which is preventing discharge to the Countess of Chester hospital. A range of organisations have good practice that is preventing admissions but, clearly, to get upstream of that is really important.

Mrs Trevelyan

Is there a particular investment in which we might more effectively pre-emptively spend this £800 million—it is a disputed figure—at the front door so that we do not have the failure at the other end?

Dr Kathy McLean

Yes. I quoted the Leeds example, and they were able to use the money and reinvest it in other ways of providing care. They used it for some elective care over the winter. Clearly, when you release the money from the bed days, you are able to use it more proactively. The other thing that the ECIP team are doing is focusing on the more simple discharges—the ones that are less complex—which makes a great deal of difference, because actually that is 90% of the patients who need discharging. By putting in place the good practice, they provide the good leadership. A lot of the practice for the simple discharges flows over into the more complex ones and creates space so that, for example, you do not have to move elderly frail people around the hospital from bed to bed, which is a key point in deteriorating their abilities.

Mrs Trevelyan

Do we have enough geriatricians in the acute parts of our hospital system?

Chair

You may be a bit biased, Dr McLean.

Dr Kathy McLean

Perhaps I am slightly biased. It is certainly an area where we need a lot of expertise, and I think it has at times been quite difficult to recruit. It varies across the country, but it is certainly an area where we need to ensure that we have the right sort of expertise. It is not just people working alone as consultants; the multidisciplinary team is clearly really important. It is really important to have the processes right from the front door all the way through the organisation, and what we found through our pilot work is that it is not just about the money. It is about the processes for assessment, and if those are done well and slickly early on, we can demonstrate that patients can move through the system a lot more quickly.

Karin Smyth

Just to pick up on Mrs Trevelyan’s point about having more geriatricians in hospitals, do you think that trusts are the place to have them?

Dr Kathy McLean

I think you need both. The model of community geriatricians is very helpful as well, because that can support the discharge.

Karin Smyth

It can help them by not going in in the first place.

Dr Kathy McLean

And prevent them from going in in the first place. The Report shows that the number of organisations with frailty units has gone up, which is a really important part of managing this because it is less about age and more about the comorbidities and the frailty of patients over 65 or 75.

Jon Rouse

This is a very good example of one of Simon’s forms of integration. As well as having significant numbers of geriatricians working in the hospital close to A&E and in the frailty units, it is about crossing those organisational boundaries so that you have geriatricians who are working in the community and in the hospital so that they are part of the care pathway, enabling people to go home and making sure that they are being cared for properly when they get home. Again, we have some best practice examples that take that approach, such as Newcastle and Yeovil, but that has to become the norm.

Mrs Trevelyan

Mr Stevens, are we doing enough? Is the NHS actually focusing on that? In education we have a lack of physics teachers, so we are paying people £30,000 a year to become physics teachers. Are we looking at that? The ageing population is going up, not down.

Simon Stevens

Just to build on the conversation that you have just had, the physics teachers in this sense are probably GPs and community nurses. We have published within the last month or six weeks the General Practice Forward View, which essentially makes the case or fesses up to the fact that the NHS has underinvested, relative to other parts of the system, in primary care over a decade and we must do something about that because ultimately how will we support people at home and keep them fit and healthy? It will be the primary care system and the extended primary care system, which might also include embedded consultants from some of the medical disciplines, community nurses, therapists and others. We are going to publish—next month in fact—the new voluntary GP contract, which will substantially expand the scope of what is included within primary care to include community health services, some of the therapy services, and possibly some of the medical services that previously went on in outpatient departments. As we do that, it will be on a per person, population, capitation basis. One of the measures that they will be held to account for is whether they are avoiding people who end up as emergency hospital admissions but do not need to be. There will be a set of metrics alongside that publicly and transparently.

Mrs Trevelyan

Which is great, but in the short to medium term the increasing age and the continuing rise in A&E admissions is of over-65s. Surely the best people to meet them at the door are geriatric consultants, and if we have not got enough of them in frailty units or treated under any other framework, we will continue having them at £300 a bed in our hospitals when they do not need that.

Simon Stevens

Geriatricians are very important, but they cannot be seen as distinct from what is happening to acute medicine in hospitals. The Royal College of Physicians has an important programme, with which I am sure you are familiar. The Future Hospital Programme is looking at the fact that acute medicine has tended to fragment too much now so we have lots of ologists who are not themselves looking after the holistic needs of the bulk of the patient group who are admitted to hospital as emergencies. This has particular ramifications for the viability of small and medium-sized hospitals because if you have to have a whole pyramid of ologists for every ology, all of a sudden a hospital is deemed not viable. That is the tail wagging the dog. There is great recognition now at the head of the Royal College of Physicians about the importance of generalism in acute medicine and the intersection with primary care. We are therefore, now at least, pushing against an open door between what GPs and physicians can see is needed.

Mrs Trevelyan

So you will not be investing heavily in the geriatric consultant part of medicine.

Simon Stevens

I think that is part of the multidisciplinary team, but if we just did that we would be missing a trick.

Nigel Mills

Just a quick one on frailty units, Mr Stevens. Are you saying every A&E should have a frailty unit somewhere next to it or behind it? I think only 55% have one according to the NAO Report.

Simon Stevens

Do you want to answer this one, Kathy?

Dr Kathy McLean

In many organisations they are found to be extremely helpful. They concentrate expertise around older people and they are not just the doctors, as we keep pointing out, but the broader multidisciplinary team, which is really important. They allow that expertise to come to people immediately. A lot of organisations have found them very helpful, but whether they are appropriate for every single hospital is a debate.

Nigel Mills

Do you think only half is right? Figure 7 suggests 55% have one.

Dr Kathy McLean

Which has risen from, I think, about 29% previously.

Nigel Mills

Are you saying to hospitals that this is a really good thing and they ought be doing it, or are you just waiting and hoping?

Dr Kathy McLean

The model we tend to adopt is to ask organisations to go and look at those that are doing it well and if they find that useful to them and they can translate that, that is what they do. I think it is about checking to see whether it is applicable in their area. The model may be different in some places and it may not be appropriate.

Caroline Flint

We have something called the Mallard ward in the Doncaster hospital in my area, which has been cited as really good practice for dementia. It is a dementia-friendly ward. I find it a bit difficult to understand, given all the evidence we have around a growing older population and all the associated issues that arise with that, why your body, NHS England and the Department of Health seem so nervous of championing what should be expected in more places within our health service. You seem so reticence about that. Do you feel reticent about saying, “This is good; this is a bench mark that should be happening everywhere”?

Dr Kathy McLean

Not at all. It is not about reticence; it is actually about pointing out good practice and encouraging organisations. As Mr Evans said earlier, 51 other trusts have been to have a look at Northumbria. To point out where the best possible practice is so people can adopt it is really helpful, but sometimes, in different places, it is not quite the model that is best suited to their own. They may have a slightly different way of doing it.

Caroline Flint

Don’t you think politics—with a small p—and fiefdoms sometimes get in the way, with people saying, for example, “You know what, I know I am director of this, you are the director of that.” The best solution is for us to get rid of some of those titles and probably integrate, and some of the reticence against doing that is possibly because people are worried about their own positions and the politics involved in that. Therefore, who is the champion of the best models?

Simon Stevens

I do not know whether Kathy would agree with this: I think that is often a fair point across the health service, and that is true in health systems across the world. There are examples, where the evidence base is very strong, where we have been pretty directive, as you know, across the NHS. We have said you have got to have a stroke unit and that major emergency trauma is going to be concentrated in a smaller number of centres. As a result, hundreds of people are alive now who, if they were knocked over by a bus, wouldn’t have been even three years ago. So yes, we absolutely do that where the evidence is clear. Perhaps, in the case of the frailty units, we are talking about two or three or four alternative models, but you have got to have one of those two, three or four models. The point is that you cannot just muddle through.

Nigel Mills

What I have not got totally clear in my mind—this may be one for you to start with, Mr Stevens—is exactly whose fault is this problem? Is this an NHS fault? Is it a local government fault? Is it a care provider problem that is causing this? Where do you think the main causes are?

Simon Stevens

We have looked at this pretty hard over at least the last 18 months, and it has received an enormous amount of time from people in the NHS, from social care and from Ministers as well. Every time you think you have come up with a single answer—“If we could just sort this out, all would be well”—it turns out that it ain’t like that. So, the disappointing response is that it is a combination of stuff, and that combination seems to differ in different parts of the country. I think we have got an increasingly clear view as to what the good recipe would look like; it is not necessarily to Mr Bacon’s satisfaction in terms of a mandated structural solution, but certainly in terms of the care processes which, whatever your structures are, you have got to have in place. That is what we have now got to drive.

Nigel Mills

What proportion of the causes of delay do you think are down to issues within the NHS’s control, rather than issues outside of the NHS’s control?

Simon Stevens

As measured on the returns that are provided by hospitals and others themselves, it is about two thirds to one third.

Chair

So, to be clear, that is two thirds NHS, one third social care?

Simon Stevens

Two thirds NHS, one third social care. The social care proportion has been increasing; that has been the main driver of the increases, as the NAO Report says. I think the NHS number itself probably may not be completely straightforward, because it is measured from the discharge from a hospital. If you discharge to a community hospital or a community bed, and then that community service cannot themselves discharge the patients they are looking after into social care, that will not show up on the radar of the acute hospital itself. It might look like it’s some other part of the NHS, but it is because it is getting sort of blocked up further down the system.

Jon Rouse

Therefore a key part of your answer is that some of those systems that are doing best are ones where all the system owns all of the problem, and they do not distinguish between whether this is a social care discharge or an NHS discharge.

Mr Bacon

Thank you. That was a good answer to my earlier question.

Simon Stevens

We finally got there; stumbled across it.

Mr Bacon

It took a while but it came there. I would have thought there is a blindingly obvious corollary, which is that it is all very well talking about leadership, but there needs to be an “it” that is led, doesn’t there?

Nigel Mills

We think it is roughly two thirds to one third an NHS problem. Ms Mitchell, I guess you are happier with that than perhaps where we thought we were going to be at with the Report?

Sarah Mitchell

We totally understand that and we’re not happy about it at all. There is absolutely nothing right in someone not having a safe and timely discharge. I think what we have seen is increasingly elderly people coming into hospital. They need time to recover and convalesce from what might have been a really traumatic experience for them, and their families need to work with them to make the right decision for their future care. We do not believe that should be done in an acute hospital at all. It is not the right place. Finding the right place is what the discharge to assess and the step-down arrangements have been about. Actually we have seen some quite innovative stuff coming out of this winter particularly, where I think trusts and local government have come together to see how they might fund, together, step-down and discharge-to-assess beds, and get people home so that they can make their decision from a place where they feel comfortable. The funding shortfall is real, and local government want to be part of the most innovative things that we were talking about, for example, the new arrangements in primary care. In A and E where we have had multidisciplinary teams, home care workers and domiciliary care workers are there from 9 o’clock in the morning till 10 o’clock at night, and we have seen people go home and not be admitted. Kirklees is an example where they really invested in some home care workers, and they have achieved that. Similarly there are places where social workers are based in GP practices and in primary care, and, working as a social worker myself, my key people that I worked really closely with and depended on were the district nurse and the health visitor. That was your integrated team, and you worked really closely with them.

Nigel Mills

We appear to have a problem that we all recognise we have. It is bigger than it should be and bigger than we would all like it to be.

Sarah Mitchell

Sure.

Nigel Mills

Yet it seems on the ground that people are really working quite hard, doing the daily review of every patient who is in hospital for too long. What is your message to them? I guess this question is for all of you. Everyone appears to be working quite hard doing a lot of things, yet the problem is going the wrong way. Presumably at some point you are going to give them something different to try and do; otherwise they are going to start focusing on something else, aren’t they?

Sarah Mitchell

I think that actually the cultural change is the important stuff. We have seen the discussion—and Northumbria is absolutely a place to go and see, and to translate the messages; but if you look at Leicester, their cultural change has been across all of the organisations, and it has been about, for every single person, talking about “Why not home, and why not today?” Once you get those conversations being very different throughout the hospital and throughout the whole system, people change the way that they behave with each other as professionals, and their relationship with the patient, and the older person. When you have worked in the NHS and you have been part of that multidisciplinary team, making sure that what the patient wants is absolutely central to what happens is the success story. All the politics with a small “p”, and the worrying about people’s jobs and the pressure that people are under—if you can get people really focused on “This is right for this person,” the rest will follow.

Nigel Mills

Okay, so Mr Stevens, on that same point, how do you make people, who are already working really quite hard on this, work probably even harder to tackle the problem you said earlier was going to keep growing—we were going to see this drift the wrong way? What is your message to those people who have been really trying quite hard on this? What they should be doing differently?

Simon Stevens

Well, as the NAO Report rightly says, it is not the case yet that every hospital is applying all of the good practice that Kathy wants them to do; but I think people can now see that there are pretty big operational consequences, for their organisations as well as for patients, from not doing so. So I think this is now much more visible to people than it was 18 or 24 months ago, and I think that NHS Improvement will be working hard with those who are not yet doing 35% of their discharges by lunch time because the pharmacy is not organised, or the prescriptions were not written up the night before by the junior doctors, or whatever the particular cases may be—just to take two examples I have recently heard from hospitals I have been visiting. It is tackling that kind of blocking that will actually make a difference in terms of the internal processes; but there are these real pressures. I am not going to name individual authorities now, but you go to visit some primary care, some hospitals, and the reality is that the relationship is rather tense with the local authority in respect of social care; and the local authority, when I sit down with them and talk to them, describe the funding pressures they have got, and they do not see a way through this right now. They do not see a way through it in terms of the availability of the domiciliary care, or the access to care homes, that they would need in order to keep the system moving.

Nigel Mills

So, aside from Mr Bacon’s wholesale “chuck the system upside down and see what else we could do”, what tangible changes could be made to contracts or models that you think could make a quick win?

Jon Rouse

One of the things we are trying for 2016-17 is, through the Better Care Fund mechanism, requiring every locality to consider the use of local risk-sharing arrangements in respect of delayed discharges, so that there is a joint and agreed responsibility with respect to the extra unnecessary days that an individual spends in hospital. One of the things we struggle with is a lack of alignment of incentives between the different parties.

Nigel Mills

So are you saying that acute trusts should be exercising their powers to fine social care providers?

Jon Rouse

In 2003, you recommended that we should be very careful about going down that route, although of course that mechanism does exist on the statute book on a discretionary basis.

Nigel Mills

What is the current usage level of that mechanism? How many trusts are using that mechanism at the moment?

Simon Stevens

It is completely minimal. Basically, trusts recorded somewhere between £2 million and £3 million-worth of reimbursement through that mechanism last year. If you set that against somewhere between nought and £820 million, it is clearly just a drop.

Nigel Mills

In two years’ time, what do you think they should be charging per year? Are you saying there should be more use of that, or are you saying it might be a bit disastrous for relationships?

Dr Kathy McLean

There are some vanguards looking at the whole-population budget, which is probably a better way of approaching that. There is also CQUIN, to encourage early discharge and so on. There are other incentives, rather than a carrot-and-stick approach. That seems to work better, and that is the approach we have been largely talking about.

Nigel Mills

If you were advising a trust that had a real problem because its social care provider was not acting how they ought to be, would you be saying, “You should be using this mechanism to move them in the right direction”?

Dr Kathy McLean

The best way of using any fines is to come to an agreement on how that money should be invested in mechanisms to help reduce discharge delays. Rather than using fines in a punitive way, it is better to invest the money in the actual care. On your earlier point about what will be different, we have shown that this can be improved by doing some of the work that has already gone on. Rolling that out using the support mechanisms that NHS Improvement will use, for example, with hospitals, is a way forward, and we have already shown it in a number of organisations. We should retain a certain amount of optimism that we can do something about that.

Nigel Mills

I sensed from Mr Rouse’s answer that he thought this was something that looked to be a tool.

Simon Stevens

I think the reality is that looking out over the next two or three years, there is likely to be a widening gap between the availability of adult social care and the need for social care. That, inevitably, will show up as delayed discharges and extra pressure on hospitals. Although the data should be used to try to work out the exchange rate for a pound of cut in social care and a pound of some subset in the national health service, those data are hard to come by. Some estimates suggests that a pound out of social care equals another 35p to 50p of pressure on the NHS. That is not costed into the NHS’s funding envelope for the next five years.

Nigel Mills

Okay. I think the Better Care Fund had a target of reducing delayed departures by 85,000, but since that started the figure has gone up by something like three times that. When hospitals are doing Better Health Care plans, what are you saying to them? Are you saying, “You should be planning for a rise in bed-blocking days, but your plan should be to lower the trend”? I am not quite sure what the strategy is.

Jon Rouse

They have two-year targets. You are quite right; in the first six months, only 40% of the areas achieved the ambition that they set themselves, which is why we have taken a tougher approach in terms of the 2016-17 framework and required them to put in place risk-share mechanisms whereby they face up to the fact that they need to align incentives between the different organisations, to recognise that those extra unnecessary days in hospital are costing the NHS a certain amount per day. We might argue about what the figure is, but it is an amount of money that is being spent that does not need to be spent.

Nigel Mills

So how do you align incentives other than by charging, then?

Sarah Mitchell

May I say that the incentive for local government is that the longer people stay in hospital the more expensive they will be, whether they then go home or whether they go into a care provider, because they will have deteriorated in their mobility and their ability? So there is no incentive to leave people in hospital longer. There is no correlation between places where there is a fining system in place and good performance on delayed discharges, and there is a lot of evidence that local authorities have to put money aside to pay fines rather than actually doing something to improve their contract with a domiciliary care provider and spending that money in domiciliary care, which is where they need to be. And if we were to introduce a system of fines, we would just increase the gap that social services has to fill—

Nigel Mills

Okay, so I get that Mr Rouse is saying that we need to find some way of aligning incentives, and the only idea that we’ve had so far is one that everyone thinks is a bad one—

Chair

And also didn’t work before.

Nigel Mills

So, Mr Rouse, I’m trying to work out what you are suggesting.

Jon Rouse

So it could be a local agreement as to how you are going to invest in some additional stepdown care, with different parts of the system making a contribution to that in terms, therefore, of aiming to reduce the cost of delays through an invest-to-save mechanism. That is one approach that you might take.

Nigel Mills

So that is what you would expect to see in a lot of Better Health plans going forward, when they come round. But what measure are you going to be assessing? When the Royal Derby hospital sends up its Better Care plan, what are you expecting to see? Are you expecting to see a fall in these bed-block days in return for the money? Are you expecting to see a reducing increase—? I am just a bit unclear now as to what measurements you will want them to come up with.

Simon Stevens

So, there is Better Care Fund maths and there is the real world. Okay?

Chair

How honest and refreshing, Mr Stevens. Carry on. Please give us this maths lesson we are keen to hear.

Simon Stevens

The Better Care Fund maths was driven by the fact that it was money taken off NHS spending and rightly allocated to local government, but it was money that the year before was actually funding emergency hospital admissions. So, if those hospital admissions didn’t come down, then the patients would still show up in the hospital and the hospital would need funding for that. So that’s why BCF maths required that there be, in order for money to be released, a reduction in emergency admissions. In the real world, outside of BCF maths, what we’re actually trying to do is moderate the rate of growth in emergency admissions, and if we do that over the next three, four, five years that will count as success, given the growing ageing population that we are—

Nigel Mills

Okay. So, when you have got teams of people spending time producing plans, you’re almost saying, “Send us any old rubbish and we’ll give you the money, because we know it’s a different world.” Is that the message you’re sending out today?

Simon Stevens

No, I think we’re saying for the BCF bit, which was the £5.3 billion—

Nigel Mills

But this is an ongoing process; it wasn’t like it was a one-off bid that you don’t do again.

Simon Stevens

Well, it was, because there was a one-off—the new incremental transfer occurred in 2015-16. So there was an issue about that level of funding in that year in the baseline, but for subsequent increases this can be done in a genuine fashion and that’s what’s happening this year and in subsequent years.

John Pugh

But in the real world, there appear to be disputes—don’t there?—about the allocation of Better Care Fund money. I know my own local authority has differences of opinion with the local NHS. Are they an outlier in that respect or is that quite common?

Jon Rouse

Right now, for 2016-17 only five out of the 152 plans are in dispute—are not agreed—which is actually not bad given the pressures on both systems at the present time, and we are working through those five through an escalation route.

John Pugh

Okay.

Nigel Mills

There are a couple of other suggestions in the Report. One is the impact that delays to the continuing healthcare assessment have. Do you have any ideas for how best practice could be improved, to avoid people sitting around waiting for an assessment?

Jon Rouse

Sorry, could you repeat the question?

Nigel Mills

I think one of the issues cited in the Report is delays caused by people waiting for the continuing healthcare assessment. Is that an area where there is scope for best practice or contractual changes to speed up that process or not duplicate other assessments?

Jon Rouse

Yes, definitely—let me just start, and then I will hand over to Dr McLean. We own the overall policy framework for CHC, but obviously it is then implemented by the NHS. One of the keys here is that most CHC assessments should not need to take place in an acute hospital. Provided that you have followed your original checklist correctly and that you have a trusted approach within the care setting that the individual is going to be moving into, it is actually far better in most cases for the assessment to take place in that other setting, whether it is an intermediate care setting or somebody’s own home. One of the reasons for that is that the evidence shows that you end up with a care package that is 25% less intensive, on average, than if you had carried out that assessment in hospital. Why? Because when people get into those other settings, with the right physio and OT support and everything around them, in many cases they begin to improve and the assessment therefore becomes more proportionate to their real needs. That is one very practical, tangible thing that we need to make sure is rolled out across the country.

Dr Kathy McLean

We know from work we have done that we can streamline that process. The checklist can lead to a lot of people being screened who don’t need to be. The staff who are looking after them will often know what to do and the trusted assessors are very important, so that people are not repeating work. What we mean by “trusted assessor” is that, whichever setting the person is assessed in, all the other partners take that assessment as the correct one.

Nigel Mills

What is the prevalence of that? I have a sense from my own casework that everyone likes to do their own assessment and come up with the answer that they might like.

Dr Kathy McLean

Yes. We have been piloting some work on that. I think that, as it comes through, we will find that it would be good to roll that out further. If we can get the documentation changed in order to support that, that will be very helpful.

Nigel Mills

Figure 10 of the NAO Report suggested that trusted or joint assessor arrangements were in place in about 49% of cases. I am not sure how many actual individual patient cases are done on that basis, but are you saying that that number should be in the 90s pretty quickly—that this is a real thing that should be there?

Dr Kathy McLean

Yes. There seems to be a blockage to doing this speedily, so it is a sensible thing to maximise, and that is what we would like to see.

Nigel Mills

You are suggesting to all parts of the NHS that they should have joint assessor arrangements in place pretty quickly?

Dr Kathy McLean

I do not think it is just the NHS. I think this is across all the partners.

Nigel Mills

I agree, but that is your organisation’s power, isn’t it—to suggest it to the NHS?

Dr Kathy McLean

Yes.

Jon Rouse

I visited an excellent care home in Lancashire a couple of weeks ago: a nursing home, which had increased its number of intermediate care beds, partly because it had established a trusted assessor system, which had given confidence that those CHC assessments could be carried out in that care home to a higher level of acuity.

Q133Nigel Mills

I am just trying to work out what the measurable situation is here. Are we saying that all acute trusts or all CCGs should ensure that these trusted joint assessor arrangements are in place by the end of 2017, or something like that? I am trying to have something here that we can measure and see real progress on.

Chair

When would be a good date to aim for, for the trusted assessors to be in place? From your end, Dr McLean, and then perhaps we will ask Sarah Mitchell.

Dr Kathy McLean

Can we come back to you on that—on the good date to aim for?

Chair

Yes. We like to make our recommendations realistic—if we are minded to recommend in this area, which I cannot be sure about.

David Mowat

It strikes me that it is not the toughest of questions. Maybe I can just come in here, to Mr Stevens—

Simon Stevens

I would have thought Mr Mowat was on to something, quite frankly. I think that is a reasonable point. What’s more, I think we should go further than that, because I don’t think it is just the trusted assessor.

David Mowat

No, I don’t think it is either.

Simon Stevens

I think it is also the proportion of CHC assessments that are done outside hospital—

David Mowat

My overriding impression from today is the disparity between the way we have dealt with this subject and, for example, when you have previously given us evidence on the Carter review. The Carter review says that we have areas of excellence in the NHS and that if only we could do procurement that way everywhere else, we would save millions or billions of pounds. This is an area with massive differences in performance, in which we just get the impression that it is all pretty difficult, because everywhere is a little bit different: we have different nuances here, different nuances there. You have used words like “encouraging” people to do things, “pointing out best solutions”—I have heard the phrase “in some places that is not appropriate”. I am sure that all of that is true, but, for a start, it does not bode very well in terms of the Carter review principles. At the start of this, Mr Stevens, you gave a number: £400 million. You are the Chief Executive of the organisation that has this £400 million issue. Which of your direct reports owns the problem and is going to come to you on Monday, or the following Monday, not with a suggestion to write to the PAC about when we might ask people to do something, like Mr Mills just said. Not with that, but to say, “How far are we going to get with making progress on that £400 million, because you are the Chief Executive and it is one of the things that should be on your agenda?” Who is that person?

Simon Stevens

Our Commissioning Operations Directorate had the responsibility for driving these changes through local health system—

Q136David Mowat

So who is it?

Simon Stevens

The guy who has just taken up that role is in just his second week, replacing Barbara Hakin—he is called Matthew Swindells. So Matthew, from NHS England’s point of view, is the lucky winner of that accolade.

Mr Bacon

Is that the Matthew Swindells who was the senior responsible owner of the national programme for IT in the health service for a while, Mr Stevens?

Simon Stevens

Picking up the pieces of the mistaken national programme for IT that you so rightly dissected down the years, Mr Bacon.

Chair

I hope he has read Mr Bacon’s book.

Mr Bacon

He is mentioned in it.

Q138David Mowat

On Mr Mills’s question about when you would get this piece of standardisation imposed, which seems to be a perfectly rational thing, it has not been done yet—

Simon Stevens

Processes inside—

David Mowat

Do you understand the problem that we have here?

Simon Stevens

I do.

Q139David Mowat

There is a complete difference between what you are saying here and what you are saying about the Carter review.

Simon Stevens

Sure. I do accept that they are different and the reason for that is that here we are dealing with a system of many different agencies, some of which are outside the National Health Service and some of which are inside it, with different statutory accountabilities. It is NHS Improvement that can actually drive change inside individual hospitals. That is the accountability structure established by the Health and Social Care Act 2012. We are doing our best to work around that—

David Mowat

You say that, but—

Simon Stevens

That is actually the accountability structure in place.

Q140David Mowat

Two-thirds of it is an NHS problem though. Two-thirds of it is your problem. I think we have accepted that, roughly speaking.

Simon Stevens

On the NHS side, yes.

Q141David Mowat

Yes, so there is a lot to go after there, and all four of you, to an extent, seem to be much stronger on analysis than on solutions. I do not know if that is just the nature of the NHS or whether it is the nature of the centre. Would you accept that?

Simon Stevens

No. You would not expect me to, I know. I think it is out of recognition of the different starting points and the different conditions in different parts of the country. Mr Phillips is not here right now, but having recently been in Lincolnshire, there is a different set of issues in Lincolnshire than in Gosport, where I was down looking at what is happening in primary care. So, unfortunately, there is an element of horses for courses here.

Q142David Mowat

Can I just explore that? I do not totally understand why it is so different in these different places. In the end we have acute hospitals, we have older people, we have a number of variables that have to be managed, yet we seem to be saying that the landscape is so different that a Northumberland solution is completely inappropriate because it just wouldn’t work because everything is so different.

Simon Stevens

Sure.

Q143David Mowat

Are you sure you are right about that?

Simon Stevens

There is always a substantial possibility that I am wrong on many things and that is probably one of them.

David Mowat

The reason I asked that is in management terms there can be too much understanding of why things are different, and not enough insistence on bringing things up to the standards of the best.

Simon Stevens

If you are Guy’s and St Thomas’ hospital. you are admitting patients from dozens of different local authorities. The differences in approach between Lambeth, Southwark and Lewisham do not go unnoticed, let alone Wandsworth out to Greenwich and so forth. If you are dealing with a single hospital with a single unitary—if you in are Northumberland, for example—it is pretty clear who you are dealing with, and although it did not probably come out in the conversation, if you look at the less harmonious relationship that exists in North Tyneside, compared with Northumberland or Newcastle, you can see that even in that part of the north-east it is a slightly messier picture than perhaps a single county solution might suggest.

Q145David Mowat

All right. Just to finish off on this accountability point, you now have a direct report who will own this issue, who will be coming to you and saying, “Well, it’s £400 million last year. This time next year it’s £200 million.” That conversation will be going on—

Simon Stevens

We will own the things that NHS England can do, and Jim and Kathy will own the—

Chair

Jim Mackey and Kathy McLean.

Simon Stevens

Jim Mackey and Kathy McLean will own the things that they can do.

David Mowat

I am not sure if that is a yes or a no.

Simon Stevens

Well, it is a shared endeavour.

Chair

We have got a name.

Mr Bacon

Mr Rouse, you are a Department of Health senior civil servant, and there must be somebody in the mix who comes along and says, “Aha! The problem is that Dr McLean owns her bit and these people in such and such a place own their bit and Sarah Mitchell’s local government people own their bit, but there is a systemic problem in the way that you described.” Without having a “throw it all in the air and see where it lands” approach, which is how Mr Mills caricatured what I was suggesting, surely there is scope for experimenting rather faster, and mimicking best practice at speed to get some of the changes that are needed, because if you have the right structure, as we heard, the processes will naturally follow. When you were talking earlier, Mr Stevens, about these people fining each other, I was reminded of the train operating companies and Railtrack. Instead of fining each other, the resources should be going elsewhere. If it were being run as one system, it would be more likely that the resources would be going into solving the problems, wouldn’t it? So where is the policy piece? I know we are not a policy Committee, but where is the piece that is coming along and saying, “Here are the tweaks that are needed”?

Jon Rouse

The Treasury, through the spending review, made a very clear statement about producing an integration framework for the period from 2017 to 2020, and that policy has not yet been fully articulated in terms of how exactly that will work, but what we do know is that a significant part of it will be channelled through the sustainability and transformation plans under the five year forward view in the 44 areas, and Ministers are going to have to make some judgments within that, in terms of how permissive or prescriptive they are going to be around different models of care. There are many advantages to a bottom-up approach, because you get real ownership. If it is gestated locally and people really own it, there are many benefits to that, and I am sure we will see that through the vanguards programme that the five year forward view bodies have set up. On the other hand, there is also a need for pace, because as we are talking today, we have problems that are pressing. Ministers over the next few months are going to have to find that point of balance between prescription and permissiveness.

Chair

I am going to bring back Nigel Mills, then Karin Smyth and John Pugh. It is already half-past 6, so if we can have short answers and short questions, that will speed things along.

Nigel Mills

We were close to a meeting of minds on setting target dates for some of these, so it would be a shame not to do that. Joint assessor arrangements—is that this year? Unrealistic, I guess, because we are in June.

Dr Kathy McLean

The trusted assessor?

Nigel Mills

Yes.

Dr Kathy McLean

I think we mentioned 2017.

Nigel Mills

Do you think that is realistic?

Chair

Spring, summer or autumn? By end of?

Dr Kathy McLean

April is often a good time, isn’t it? The beginning of the financial year.

Nigel Mills

Discharge to assess schemes were being used in only 52%. Do you think they should be much more widespread and on the same timetable?

Dr Kathy McLean

Those should be more widespread, but I think that is a joint thing that we would need to commit to. Perhaps not 100% in the first instance. What do you think would be reasonable? This is very much a joint thing.

Sarah Mitchell

It is about putting a plan in place to achieve it and do it properly, and I think we are already trying to do that. It would be very confusing to the system if we had lots of different dates for different things, and I do not know how it would fit with other plans that are coming on board, but we could align them for the moment and say April 2017, and then if, taking consultation from the field, we thought that was impossible, we could come back to the Committee.

Chair

Okay. Thank you for your candour. It is amazing that you are not making it up in front of us—hopefully not. But thank you for that.

Mr Bacon

If it works, you should try it more often.

Chair

Yes, maybe we should bring you in front of us on every local issue we deal with.

Karin Smyth

Perhaps unhelpfully, I may be slightly disagreeing with some of my colleagues. I found the Report slightly frustrating because it almost gets us somewhere and then I think we lost it. In the conversation in the last hour, we made some progress, but then we seem to be going back. I did not recognise parts of this picture. Mr Stevens, you said that different things are working in different parts of the country, but at each turn, we seem to be going for a national prescription. We have had 20 pieces of guidance on this subject in 15 years. We clearly do not need any more guidance. I am not sure we need any more plans, actually. I think you know between you what is working, where it is working and where it is not working. This Report does not help us with that, and this hearing is not really telling us where things are working and where they are not. That is also where part of this accountability issue is not working. It would be a shame if we went away from this wanting a total national prescription without somehow getting beneath some of that detail about where things are working and where they are not, and why that is. Is that fair?

Jon Rouse

I think you are right in saying that we have a pretty darn good idea of what works now, in terms of the different teams that we have sent into places over the last two or three years and the guidance that we have produced. As has been said, there are some essential ingredients that every place should have, and that we should pretty systematically over the next year or so be making sure are in place, because we know they work and they ought to be core to each system. Beyond that, it gets more difficult, because in those areas that are really struggling with this, when you get down and really spend time with them, you find that the barriers are different in each place. In one place, it may be that they are grappling with a real labour supply problem on the care side, because they have full employment or near-full employment and it is very difficult to attract people to become domiciliary care workers. They are attempting different approaches and solutions, but—

Karin Smyth

We heard that in the pre-evidence session.

Jon Rouse

Yes, and it is really hard. There is no point in beating them up with a stick, because you have to own the problem commonly with them and try to find innovative approaches. I will not name names today, because it is not fair or appropriate, but there are some authorities that have been stuck at the top of the DTOC list for social care literally for years. They have been the top three or five worst-performing authorities—multiples away from even the average position, let alone the highest position—and there is clearly a leadership and relationship problem in play there. There is still a question about what you do in those circumstances with those authorities, because they are contributing substantially to the national numbers. I have said there is variation here. Those bottom 24 authorities—that is 14% of all authorities—are a third of all delays, to give you some idea of the proportionality here.

Karin Smyth

So why have we not used that work and the work of the ECIST team and so on and just focused on that, rather than continuing to shroud what seems to be a massive problem across the whole country?

Jon Rouse

We have done a lot of work with most of those authorities on a voluntary basis. Some have responded very well and their numbers have come down and stayed down, and they are to be commended. There are some authorities that were in the top 10 for a long time in terms of their rate and are now down in the pack. But there are others that either have not been properly receptive to that offer or that work or, for whatever set of reasons, have been unable to take the practice that we know works and embed it within their system. There remains, therefore, a question about what we do with those authorities in those areas that we are still grappling with.

John Pugh

I have two quick questions. One is in relation to figure 9, which talks about the rather dismal figures for the number of older patients fully involved in the decision about their discharge from hospital. Obviously, involving people takes a certain amount of time. Is getting that figure up compatible with delivering a better service, or is it to some extent just dragging out the process?

Simon Stevens

Sorry, could you say that again? Compatible with what?

John Pugh

In figure 9, there is a rather depressing figure. It mentions that “54%”—barely half—“of older patients felt fully involved in decisions about their discharge.” Obviously, you could try to correct that. The simple question I am asking is: if you tried to correct that, would that prolong the process, or could the process be done just as expeditiously?

Sarah Mitchell

I think involving people usually makes—

John Pugh

The process longer.

Sarah Mitchell

No, shorter, actually. I think part of the problem, as I was saying earlier, with not being patient-centred or person-centred, is that actually people—

John Pugh

Okay, so it’s compatible. My second question is massively parochial.

Simon Stevens

Can I supplement that answer with an additional flavour? I think 99 times out of 100 that is right, but it has been the case that some hospitals report that where they have patients who would be self-funded in a care home, sometimes relatives take time to realise that that is unfortunately now the situation confronting, typically, their parent. Being clearer about what expectations the NHS has of families is also part of the deal, so we published with the LGA, ADASS, Care England and the UK Care Homes Association a sort of guide setting out in pretty straightforward language what the deal is, including a section titled “Refusal to leave hospital”, which gets into this in straightforward terms.

John Pugh

It is good to have that on record, because it hasn’t been touched on so far. My second question is massively parochial. I was fascinated to come to this session, because my own local hospital has had appreciable problems. The evidence for it is ambulances turning up in large numbers and waiting there because they cannot transfer patients into A and E because they need to free up beds, because a lot of the people being transferred into A and E need to be moved on to wards. I would make a plea for somebody knocking heads together, or some level of integration or dirigism there. There are a number of parties involved, including the local commissioning group, all of whom are not quite clear whose fault it ultimately is. When I looked at the statistics for my local hospital, I found that the percentage of people aged 65-plus who were actually admitted was a bare 33%, compared with Peterborough and Stamford hospitals in Stewart Jackson’s constituency, where it is 60%, and in Kevin Foster’s constituency, where it is 60%. This leaves me sceptical about NHS figures in general. Can it be that people in Southport are so incredibly hardy that they hobble away after a visit to A and E, and people rocking up in Peterborough and Stamford insist on being admitted, or the doctors do? Does this show something about varieties of risk-averseness in the system? I simply can’t explain that figure.

Simon Stevens

On average, I think about half of A and E attendances result in admissions, so there is a spread around that, but it will be a function partly of what the other alternatives are. If, in your area, as well as the hospital, there is an urgent care—

John Pugh

We have a very aged demography, you see, which is why it is surprising.

Simon Stevens

Yes, or a minor injuries unit, or some other route that might be taken by those patients—

John Pugh

No, there’s none of that.

Simon Stevens

Well, maybe there is in Peterborough and Stamford. We need to look at this. Different channels will therefore dictate what the admission rate appears to be, relative to the total footfall in an A and E department. In some places, people go to an A and E department when in other geographies, they would instead go to an urgent care centre.

John Pugh

There is no alternative in Southport. Do you not find a variance of that kind very interesting, if not worrying?