ADDING LIFE TO YEARS
ANNUAL REPORT 2002-03
CHAPTER 4 : WORKING IN PARTNERSHIP TO PROVIDE HEALTH AND SOCIAL CARE FOR OLDER PEOPLE
The section of the report Adding Life to Years dealing with the health screening of older people pointed out that the current arrangements for the routine health checks carried out in Primary Care for people aged 75 or over have a number of disadvantages. Although the checks usually comprise an assessment by a nurse or doctor, mainly aimed at picking up new or worsening health problems, they are nevertheless carried out in a number of different ways across the country. They can fail to identify growing dependency or deteriorating mental states. The information they provide is not helpful to the planning of services, either locally or nationally, for Scotland's one-third of a million people aged over 75.
Older People's Views
Older people need to feel secure - mentally, physically, economically and socially. They want to be valued and be a part of the community; retain dignity; have control over their lives and to have access to help, if needed, at any time. Most importantly, older people want to be treated as individuals with a right to express opinions, choose life and make mistakes.
The Joint Futures Agenda aims to deliver better results for all community care groups through more integrated working between NHSScotland and local authorities. Initially much of its focus is on older people. Implementation is progressing well across Scotland.
On 28 February 2003 the national partnership of the Executive, COSLA and NHSScotland, issued the 'Next Steps' letter, setting out the plan to deliver full implementation across the whole of community care by April 2004. Single shared assessment, joint resourcing and joint management for older people were to be in place by 1 April 2003 and would extend to all community care groups by 1 April 2004. This is a major undertaking for local partnerships, and involves training up to 20,000 staff.
Under joint management every area has a new high-level partnership body to take holistic decisions on strategy, services and resource use. A number of services are being managed jointly. In the context of joint resourcing, every area has declared a resource envelope - some more comprehensive than others - and begun to develop more sophisticated joint financial planning.
Single shared assessment (SSA) provides faster assessment, quicker access to services and places less demands on older people and carers. Systems are in place everywhere and most have arrangements - some more developed than others - to share information appropriately and to enable staff in one agency to access resources in another. Older people are now getting the benefits of SSA. Building on information from the SSA the Resource Use Measure (RUM) groups older people according to their needs. It will help managers and professionals make better use of health, social care and housing resources. It is already being implemented in five areas, and will cover the whole of Scotland by the end of 2003-04.
Supporting Older People at Home
If we are to support older people better at home, they need more innovative, flexible and better targeted services. The Executive provided 24 million in 2001-01 and 2002-03 and 48 million in 2003-04 to joint rapid response teams in every area to support early discharge from hospital and prevent unnecessary admissions; to provide 22,000 more weeks of short breaks to enable carers to continue caring; to support 1,000 more people at home (and admissions to hospital avoided); and to give 15,000 more people low level support (shopping/household help).
These are early days, but the signs of material benefits for, initially, older people from the Joint Future Agenda are beginning to emerge.
Delayed Discharge is a problem that has existed for over a quarter of a century. Detailed planning and joint working between Local Authorities and NHSScotland is of the greatest importance in tackling delayed discharge. Reducing delays is not just a matter of funding. It is clear that there are different pressures in different areas. The Action Plan on Delayed Discharge was launched on 5 March 2002 and it outlines a range of key long- and short-term actions needed to resolve the problem and sets out a clear national strategy and targets for delivery. The Action Plan is clear that vulnerable people must be cared for in the most appropriate care settings.
Census information on delayed discharge is published by the Information and Statistics Division (ISD) of the Common Services Agency on a quarterly basis, with first data set relating to September 2000. These data provide ongoing validated information on cause, numbers and duration of delays. The most recent census figures, from 15 January 2003, show that the most common reasons for patients being delayed in hospital are the wait for a place in a nursing home (21.4% of total cases): the wait for public funding for a place in a nursing home (16.4% of total cases); and the wait for assessment (12.0% of total cases). Figures from the January 2003 ISD census also show that the total number of patients clinically ready for discharge was 2,545 compared with 2,798 at the October 2003 census, a decrease of 9.0%, and 3,116 at the January 2002 census, a decrease of 18.3%.
Well over half (62%) of those delayed between 0 and 6 months at the last census have now been discharged. Of those waiting over 6 months, 49% have been discharged and there has been a 17% decrease from the October 2002 census and a 27% decrease from the January 2002 census in the number waiting more than 12 months.
The aim is to reduce the number of delays nationally and to ensure timely, appropriate and safe transfer to next stage of care once care in hospital is complete and to ensure that more people than at present receive 'right place, right time' care.
A 20 million package was first announced in January 2002 for local authorities and NHS Board partnerships, and was intended to enable the transfer of 1,000 people to more appropriate forms of care by April 2003. 25% of the new money was provided prior to submission of local plans from partnerships (i.e. from 1 April 2002) to kick-start action on delayed discharge, with the remaining money provided on 20 June 2002.
The Scottish Executive is monitoring performance closely. If partnerships fail to deliver, a Support Team will be sent in to help the partnership to resolve any difficulties.
An additional 10 million funding has been made available for delayed discharge for the next 3 years, bringing the yearly total to 30/30/30m. Longer-term work on delayed discharge will include the commissioning of a review of the range and capacity of community care services, with a strategic review of care home provision and a review of the regime between local authorities and NHS Boards around the care of older people. Above all, the problem of delayed discharge requires a partnership approach between those responsible for delivering and managing care.
Capacity Planning and Longer-Term Action on Delayed Discharge
The Scottish Executive's Delayed Discharge Action Plan requires the Executive to carry out reviews of the range and capacity of community care services for older people over the next 5, 10 and 15 years, including a strategic review of care home provision to identify the most effective way of developing and managing the market to meet future needs.
The right range of services must be in place to ensure that older people are not delayed unnecessarily in hospital and that the balance of care continues to shift from residential to home-based settings. The work will be carried out in partnership with health and local authority colleagues and in consultation with independent sector care home providers. This work will form the basis for longer-term national and local planning of future developments.
INTERDISCIPLINARY RESPONSE AND INTERVENTION SERVICE (IRIS)
The Interdisciplinary Response and Intervention Service (IRIS) in the North Glasgow Trust is one of many examples of innovative schemes designed to provide an alternative to emergency admission of older people to acute care. It aims to provide a bridge between acute care for frail, elderly patients and the area Social Work teams. It works by using IRIS teams at the three hospitals to accelerate the movement of patients through rehabilitation and back to their homes, but also by picking up admissions - A&E or acute medical - to see whether their entry to the hospital is properly justified.
IRIS is provided with site bases at Glasgow Royal Infirmary and Lightburn Hospital; Stobhill Hospital; and Western/Gartnavel General and Drumchapel Hospitals. The focus of the service is to provide support and rehabilitation during/following a crisis period, for patients at the interface of Primary/Secondary and Social Care. Although there is no lower age limit for inclusion to the service, the majority of patients included are over the age of 75 years. The service is aimed at frail older people who have had a functional deterioration, are socially isolated or live alone and require short-term intervention during an acute phase of illness/injury or similar crisis episode. IRIS is led by a Consultant Geriatrician, and has a named link Geriatrician in North, East and West and a Service Manager across all the sites. The three sites have Clinical Team co-ordinators for each of the Interdisciplinary Teams.
The service operates 7 days a week between the hours 0800 to 1800 Monday to Friday and from 1000 to 1800 at the weekend. All patients are assessed by a member of the IRIS Team prior to inclusion and all patients included will be visited in their own homes within 24 hours of inclusion/discharge. Input from the Team normally lasts a maximum of 4 weeks, but where a patient requires further service input, the service can be extended.
Research-based Development of Scottish Primary Care
Primary Care Trusts in Scotland are investing in a major initiative that will carry out research-based development of Scottish Primary Care. This is a joint venture between Primary Care Trusts (PCTs) and universities, facilitated through the Scottish School of Primary Care (SSPC). SSPC is the national organisation promoting research and increasing capacity for research in primary care across Scotland and is part of NHS Education Scotland. This initiative, which has been in operation for 18 months, is based on four R&D projects identified by the PCTs and each has signed up to one of the following:
integration of health and social care for older people
integration of community mental health services
barriers and facilitators to provision of effective Diabetes Retinopathy
preventing emergency hospital admissions of older people
The key outcomes for these four projects are:
analysis of organisational features impacting on Diabetes Retinopathy Screening services
cross project comparison:
uptake, impact and sustainability of different evaluation and research strategies.
Comparison of different datasets (ISD statistics, mapping of services, professional perspectives, patient views) in order to explore variations in emergency hospital admissions between Primary Care Trusts uptake, impact and sustainability of different evaluation and research strategies.
The initiative as a whole will constitute a case study of how to undertake research-based service development in Scotland. The four projects are using different approaches to R&D. The approaches are being compared in relation to these questions:
What theories and models have been used to conceptualise R&D?
How were these applied in practice?
What were the barriers and facilitators for research-based service change?
In what ways were barriers facilitators context dependent?
How was success defined and measured?
The lessons learned from this initiative are grounded in the day-to-day realities of the NHS in Scotland and will have general application across Scotland and beyond.