UNISON Response to
Greater Glasgow Health Board "Elderly Services: Proposed Changes to Continuing Care"

September 2000

1. Introduction
2. Background
3. Quality of Life : Frail and Elderly People
4. Hospital Closures - Recent History
5. Provision of Long Stay Care
6. Re-investment in Elderly Care
7. Morbidity and Re-admission
8. Conclusion
9. Recomendations

1. INTRODUCTION

1.1 UNISON as the largest public sector trade union in Scotland represents the interests of 15,000 members in all sectors, which provide care for the elderly across the Greater Glasgow Health Board Area. Our members are employed by three NHS Health Trusts, Glasgow City and neighbouring councils as well as the voluntary and private sector.

Our members whether in the traditional providers such as the NHS, Local Government or in the voluntary/private sector provide high quality care.

A significant number of them also provide care for elderly members of their family who currently live in the community and will undoubtedly be directly affected by any decision that Greater Glasgow Health Board decides to implement.

This response is not intended as an attack on `alternative' provision but as a direct response to the consultation to close Cowglen and Blawarthill.

2. BACKGROUND

2.1 On the 18th of April, Greater Glasgow Health Board considered the paper `ELDERLY SERVICES- PROPOSED CHANGES TO CONTINUING CARE.'

The paper asks GGHB to,

• Note progress on jointly developing and implementing new models of services to elderly people.
• Note the financial issues in elderly services.
• Consult on the closure of Blawarthill and Cowglen Hospitals.

As well as consulting on the closure of these facilities the Board invited comments on how, if their closure plan is successful;

a) The long stay places should be provided.

b) Other related resources should be reinvested in elderly care.

UNISON would state that the method of consultation in this exercise has been disappointing. We fully expected that the Consultation would have flowed directly from the publication of the proposals, but in fact it was delayed for a number of weeks. Even then it was pressure from UNISON and the local community groups that made GGHB set up public meetings which were extremely critical of the plans to close both Blawarthill and Cowglen.

3. QUALITY OF LIFE : FRAIL AND ELDERLY PEOPLE

3.1 UNISON are not convinced that the Health Board has made the case for the closure of these facilities. UNISON has consistently asked for, and been denied, data concerning morbidity rates for the elderly in the community compared to those in NHS care and for data concerning the levels of acute admissions and re-admissions to hospital amongst this patient group.

UNISON has also asked for data concerning morbidity amongst elderly people who are transferred from one type of care provision to another. To date this information has not been provided and UNISON must therefore assume that this type of basic information does not exist. This is obviously an area of concern.

3.2 It may be that the data that the Health Board holds concur with the verbal evidence obtained by UNISON in detailed consultation with our members, patient groups and community organisations. It is our belief levels of morbidity and re- admissions for this group of people is unacceptably high.

It is the case now that there is just not the resources or staffing in Social Care, Home settings and Nursing Homes to take care of elderly and frail patients being discharged. The evidence for this can be found in a recent report produced by Help the Aged Scotland who express great concern with regards the quality of medical and therapeutic care given to people in Residential and Nursing homes.

This view is further supported in the Annual Report from the Chief Inspector of Social Services, England and Wales, who states that there is a " Crisis in Social Care" due to poor recruitment and retention of staff, inadequate training and resources. There is no evidence to suggest that the position in Scotland is any better.

4. HOSPITAL CLOSURES - RECENT HISTORY

4.1 UNISON believes that it is wrong to view these current closures in isolation; they come on a backdrop of significant under-investment across the health service in Glasgow that has lasted for more than two decades.

In 1995 Greater Glasgow Health Board proposed a reduction in Continuing Care Beds across the Greater Glasgow Area from 1438 to 964 by April 1998. Amongst the closures intimated at that time was Cowglen Hospital whilst Blawarthill was to see a significant reduction in beds.

At that time UNISON in its submission to the then Conservative Secretary of State condemned the proposals as a "virtual demolition of NHS Continuing Care in the Glasgow area". UNISON believes that the current proposal amounts to the same demolition today as it did in 1995.

IT WAS RIGHT FOR UNISON TO OPPOSE THE CLOSURE THEN IT IS RIGHT FOR UNISON TO OPPOSE THESE CLOSURES NOW.

The 1999/00 Health Improvement Programme committed health professionals in Glasgow to work jointly with Local Authorities to

• Strike the right balance between institutional and community care and between health and social provision enabling people to live at home wherever possible.
• Achieve health and social services, which are integrated and cohesive, involving pooled skills and resources.
• Improve the facility and range of services available.

UNISON does not believe that the balance has been struck, the proposal by GGHB amounts to nothing more than `robbing Peter to pay Paul.' The proposal to take care provision from one sector and place it in another will not necessarily improve the range of services available nor has that been evidenced by the Board in its paper.

WITHOUT A PROPER AND FULL AUDIT OF THE CURRENT PROVISION FOLLOWED BY SIGNIFICANT TARGETTED INVESTMENT, CARE OF THE ELDERLY SERVICES IN GLASGOW WILL NOT BE IMPROVED.

4.2 BLAWARTHILL

UNISON believes that the statement that Blawarthill Hospital is built "on the site of a Victorian hospital" is misleading. It is accepted that the site once housed a Victorian hospital. The current accommodation provided for patients was not built in Victorian times. UNISON is disappointed that GGHB in their consultation document appear to have attempted to make use of the feeling that everything Victorian needs to be replaced.

In UNISON's response to the last paper under the Conservative Government in 1995 we were critical of plans for bed closure, arguing as we did for an increase of 137 beds in the elderly and frail sector in Greater Glasgow. The community groups in this area were promised a further 30 beds on top of the existing provision by GGHB in 1997. This was never honoured although the closure of Knightswood Hospital went ahead.

Having committed themselves to the need for extra beds in 1997, where is the Boards evidence to propose further cuts?

Blawarthill is an award winning hospital providing a high standard of care in an area of Glasgow with an increasing Elderly and Frail population. Instead of closing such a facility it should be built on to ensure that the highest level of patient care is maintained.

It should be remembered that in many cases this is the fourth time that staff have faced closure of their workplace. It is to the staff's credit that they have maintained the current high standards, which have been recognised by the patients and their families.

4.3 COWGLEN

Whilst UNISON accepts that the fabric of Cowglen Hospital may well be poor, it should not be considered in isolation.

The Scottish Health Advisory Service (SHAS) visit in 1998 commended the high standard of clinical care. UNISON is disappointed that GGHB have decided to refer to the current poor fabric as a primary reason for closure.

In 1995 the hospital was assessed by GGHB as being in an adequate physical condition. At that time the Board spent capital upgrading the fabric of the building.

UNISON believes that the building is structurally sound and must question whether or not the facility has been deliberately run down over the past five years. There has been some investment, mainly from the community, more from the Health Board would see an improvement in patient care at the site.

Whilst UNISON welcomes the move away from Nightingale Wards in a general sense, we realise that for the majority of elderly and frail patients with complex care packages there is a benefit in the social interaction obtained in this setting. UNISON is far from convinced that these patients would benefit from a single room with en-suite facilities. Many who are admitted or remain in both Cowglen and Blawarthill are incontinent and require the care of nursing staff to assist them.

5. PROVISION OF LONG STAY CARE

5.1 Whilst supportive of the shift away from institutional care, UNISON believes that there is a need to recognise this practice in the past simply led to the privatisation of continuing care.

UNISON believes that it is important not to confuse the image of traditional institutionalised care with modern hospital focussed health care. The levels of community support and interaction with Blawarthill and Cowglen clearly evidence the view of UNISON that health care facilities, like schools should be seen as community facilities.

5.2 Local Authority provided residential homes will not care for the most dependent elderly people. They currently do not have the levels of expertise to provide complex care packages. The result is that those who have a complex care need find themselves being cared for in the private sector.

UNISON has already referred to the annual report of the Chief Inspector for Social Services in England and Wales. We believe that the concerns highlighted in that report are transferable to Scotland and the GGHB area.

5.3 UNISON condemns the decision by GGHB to fund places for the elderly in the nursing and residential sectors at the expense of NHS beds. Across the UK NHS long stay beds have been reduced by 38% whilst private nursing home beds have increased by 900%. The picture in Glasgow is no different. In 1995 there was 1438 NHS care of the elderly beds in Glasgow with some 2153 private nursing home beds. In the year 2000 that figure is adjusted to depict 822 NHS beds and 2500 residential beds.

The current proposal, tabled under a Labour Government will take the current 822 beds and reduce them to 582.

UNISON is concerned that the proposals put forward by the Board could result in the most elderly frail in our society being cared for in a less safe, less clinical environment.

5.5 Currently at anyone time up to four trained nursing staff are on duty in the NHS environment, the ratio in private nursing homes is somewhat less than this. The continued use of untrained or semi skilled staff in the private sector where profits are put before care does not fill UNISON with confidence that those clinical standards will be maintained.

Further, evidence taken by UNISON in our consultation with members and patient groups would support our view that the patient journey for the elderly is far from smooth and that whilst some private health care providers are professional in their approach the monitoring system is not robust enough to ensure the care and safety of the elderly.

6. RE-INVESTMENT IN ELDERLY CARE

6.1 UNISON is supportive of any commitment to re-invest in elderly care, the mark of a civilised society should be the care of its oldest and youngest citizens. UNISON believes that the investment should take place now before elderly frail people are transferred to a community setting.

6.2 UNISON believes that Glasgow Primary Care Trust is already concerned that it does not have sufficient trained District Nursing staff and that any increase in elderly care provision in the community will have further significant impact on the current staffing resources.

6.3 Occupational Therapist services are stretched to the limit and UNISON believes in some areas have expended their current budget provision. The result is that elderly people are not receiving the essential aids and adaptations that they require to be made to help them live in the community.

6.4 Reduced warden services across Scotland, which have been replaced with `alarm pull systems' regularly fail. In Glasgow this is particularly prevalent at `peak times.' UNISON was concerned to hear that in some areas elderly people are expected to purchase this service for themselves.

6.5 Services are already struggling to cope across the city and other Local Authority boundaries.

Elderly people and their families are being expected to pay for their care provision and yet there is no consistent application of charges where these are deemed as appropriate.

Continued funding pressures on Local Government have resulted in significant reductions in some essential services such as meals on wheels and home help provision. As financial pressures increase on Local Authorities and older people are expected to pay for elements of their care package this compounds the current problem of pensioner poverty. UNISON is concerned that even if initiatives are put in place to tackle pensioner poverty, the wealthier pensioners become, the more of their improved income will be consumed by the provision of care.

6.6 The Board attempts to justify its proposals by indicating that a mixture of nursing home and residential home places will replace the 240 NHS beds that will be lost. It goes further in its justification by pointing out that by transferring these beds into a non NHS environment could release up to £6000 per patient from the DSS.

The proposal put forward by GGHB makes no comment on the fact that the Local Authority is required to determine what financial contribution the individual concerned can make towards their own care costs.

A recent report by the Joseph Rowntree Foundation highlighted that in many cases Authorities do not monitor an individual's assets, so in many cases people were continuing to contribute to the full amount when in fact they were entitled to state help.

6.7 The Macpherson report describes the current system as designed around different bureaucracies, rather than the needs of individual older people. Macpherson adds that the system is characterised by its complexity and unfairness. The number of different providers and funders of care, each of whom have different management or financial interests may work against the interests of the individual client.

The current system has no support in the community and is not trusted by the elderly. Apart from the fact that many of these people bought into a principle that promised to provide care from the "cradle to the grave" GGHB seems to be determined to ignore the fact that by transferring care provision from the NHS to a social model elderly people and their families feel let down, particularly when they then are expected to pay for assistance and care.

UNISON believes that if the elderly are to stay in their community, the role of advocacy should be developed locally. Far too often it is reported that the elderly are not claiming all of the benefit they are entitled to. New initiatives can be complex and difficult to access at the best of times without being a frail elderly person who is reliant on family and care providers. Further if public bodies are serious about being open and accountable they should be committed to helping service users access them in a way that allows them to contribute positively on issues that affect them.

UNISON believes that if the Government and local Health Boards are committed to making Care in the Community a success for those who rely on the service it is essential that investment is made in the people who provide the services at the front line. The difference between UNISON members in the traditional public sector and the voluntary/ private sector is too great. Work needs to be undertaken now to achieve a `coming up' for those employees who are currently employed on cost cutting terms and conditions.

If GGHB are serious about providing high quality care for the elderly, they need to realise that high quality public services are best delivered by well trained, directly employed staff who put the needs of the service and the communities that they serve first.

7. MORBIDITY AND RE-ADMISSION

7.1 UNISON has consistently asked for data concerning morbidity rates for the elderly in the community/social care sector compared to those in NHS care and for data concerning the levels of acute re-admissions to hospital amongst this patient group. UNISON has also asked for data concerning morbidity amongst elderly people who are transferred from one type of care provision to another.

To date this information has not been provided and UNISON must therefore assume that this type of basic information does not exist.

7.2 UNISON believes that without this basic analysis having been undertaken GGHB's proposals amount to nothing more that rough guesswork. We believe that this is not acceptable in determining the future of care for the most vulnerable in our communities.

8. CONCLUSION

8.1 There is a serious risk that the general public has no confidence in Care in the Community. The concept of integrated community care is not new.

UNISON has long argued that where care can be best provided in the community, people should be given the opportunity to stay in the comfort and familiarity of their own home. It is our view that, that care should be provided by directly employed public sector workers, who are paid a fair day's wages for a fair day's work.

To do this will require a massive investment in Public Services and a commitment from Government at all levels and Health Boards that private provision is not necessarily the best provision, especially in the care of the most vulnerable members of our society.

8.2 UNISON can only condemn GGHB for their unashamed proposal to pay for the short fall in Glasgow City Councils social care budget by closing NHS beds. We believe that these services should complement each other rather than at each other's expense.

8.3 To date no evidence other than a financial benefit has been put forward by the Board to support the view that the hospitals at Blawarthill and Cowglen should close. It would therefore, we believe, be fair to conclude that the decision to effect these bed cuts is purely a financial one.

UNISON believes that there is overwhelming support for the retention of the existing facilities and would urge GGHB to listen to these views.

9. RECOMENDATIONS

UNISON would recommend that;

a) GGHB retain the existing facilities at Blawarthill and Cowglen, as there is little or no evidence to suggest that the alternatives provide a higher standard of care,

b) GGHB undertake an extensive study of morbidity levels and reasons for these deaths amongst the elderly and frail people in the GGHB area,

c) That linked to the above study analysis should be carried out to determine the levels of admission, re-admissions and reasons for, within this patient group,

d) From the above study and analysis, a comprehensive targeted investment should be undertaken across both the health and social care provision in the Greater Glasgow area; and

e) GGHB should commit itself to the continued provision of continuing care of the elderly at a level not lower than the current provision.

JOSEPH S LYNCH
Regional Officer
j.lynch@unison.co.uk