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Report of the Joint Future Group

CHAPTER 3 REBALANCING CARE FOR OLDER PEOPLE

Context

3.1 All the evidence points to most older people wanting care at home whenever possible. That is what the research says; that is what older people continue to tell us; that is what the policy aims for; and that is what agencies say they are aiming to do. One of the issues therefore is to understand better the paradox of that strong commitment, both nationally and locally, towards home based care and the patterns of expenditure and services, which seem to move in the opposite direction.

3.2 Between 1994 and 1999:

• Long-stay geriatric beds decreased by 2,500 (33%);
• Nursing home places increased by 5,000 (34%);
• Residential home places decreased by 1,200 (11%);
• LA home care clients reduced by 15,000 (17%), partly on redefining the role of the home help service; but staff increased by 1,300 (13%), meaning more people got intensive packages of care;
• Older people seen at home by community nurses rose by 8,000 (3%), but the number of home visits fluctuated and eventually reduced at a time when 100,000 more older people were discharged from acute hospitals; and
• Local authorities’ expenditure on home care services rose by £7m, but that on residential and nursing home care increased by £65m (both 1995-99).

3.3 A number of factors influenced these outcomes. Reducing the number of long-stay hospital places dominated the agenda. But the emphasis was much more on using services such as nursing homes which were readily available in increasing numbers, rather than on providing care at home. And the DSS transfer, despite its intention of assisting the balance of care, tended to perpetuate existing patterns. Partly that may have been affected by increases in demographic pressures and life expectancy, resulting in lower than expected turnover of existing residents. Community care as a whole was also under financial pressure — sometimes as a direct consequence of shifts in the balance of care - and often needed firmer and more focused leadership, both nationally and locally. Finally, home care services have taken time to become more flexible and respond to the challenge.

3.4 In practical terms there is also the eternal ‘bridging’ question: how to place people appropriately in residential care or nursing homes, and at the same time develop better and more flexible home care services, with due regard to Best Value.

3.5 These factors alone do not explain the imbalance between policy aspirations and reality, but they clearly influenced the outcome. Evidence is now emerging through SCRUGS4 of a significant number — perhaps as many as one in five - of residents in nursing homes capable of being looked after at home with appropriate support. There is also evidence that interventions from occupational therapists can sustain people at home, who otherwise would be in residential care.

3.6 There are also many positives. Although the alternative to hospital care was not home care, the significant reduction in inpatient beds for older people is one part (from hospital to community services) of the balance of care shift. And there is considerable innovation in both services and in partnership working. But much of this good work is found in pockets, in pilots or in projects. The resulting impression is of agencies’ ability to innovate, but an inability to convert that innovation into mainstream services. To see where the future should lie, we do not need to ‘re-invent the wheel’. There are already many innovative and effective approaches; but they need to be applied more generally. Using what works well is fundamental to our proposals. We want to raise the standard to that of the best.

The Way Forward

3.7 It was not appropriate for us to draw up the ‘ideal’ balance of care. That should be a matter for local determination within the broad policy framework which already exists. Rather, we identified 2 complementary, practical approaches to support rebalancing services for older people:

• "key" services which must be in place to support people properly at home; and
• new national and local financial, planning and service management frameworks.

3.8 These frameworks are, however, about much more than rebalancing care for older people. They are also part of the new joint working agenda. To include them in a chapter about one or the other would be inappropriate. Our proposals are therefore set out separately in Chapter 5.

Key Services to Look After Older People at Home

3.9 To achieve the desired rebalancing of care, home care services need to be integrated, robust and focused on sustaining people at home. Home care services have to change to achieve that. This is not just about social care and health services. Housing’s expertise operationally and strategically also has a part to play.

3.10 Change is also required in service priorities and ways of working. There is scope, for example, for discharge arrangements to be better co-ordinated; and rehabilitation services developed to support actively people’s independence and inclusion, as opposed to reacting to changes in their circumstances. This calls for a more concerted approach, with more multi-disciplinary inputs, including from occupational therapy.

3.11 Older people need access to a range of services — a continuum of care - if they are to be properly supported at home. We were particularly conscious of critical gaps, and identified 3 key services to which every older person who needs them should have access. They are:

• intensive support and care schemes;
• more flexible and comprehensive short break services; and
• a practical, low level shopping/domestic/household maintenance service.

What characteristics of these services do we value?

Intensive Support and Care Schemes

3.12 We recognise the need for two types of scheme:

• hospital discharge/rapid response teams; and
• intensive home support/augmented care schemes.

3.13 Hospital discharge/rapid response teams support early or timely discharge from hospital or prevent inappropriate admissions by providing short periods of intensive home-based support. Teams need to be multi-disciplinary, comprising a mix of health and social care and, where appropriate, housing professionals, have devolved budgets and clear service goals. Some schemes can also be ward or condition-specific, and some divert older people who present at accident and emergency departments. That broad effect makes joint resourcing a prerequisite.

3.14 The key factors which makes these schemes successful are:

• the speed of response to referrals;
• joint resourcing;
• dedicated and flexible resources; and
• the multi-disciplinary team providing co-ordinated, targeted care and support.

3.15 We recommend:

Every local authority area should have in place a comprehensive, joint hospital discharge/rapid response team, by mid 2001-02.

Intensive Home Support/Augmented Care Scheme

3.16 In contrast, these schemes provide longer-term support for people becoming frailer to enable them to return to or remain at home, rather than enter long-term residential or nursing home care. These schemes provide personal care of a higher level of intensity and need, more flexibly and for longer periods of the day than mainstream services. They also provide support for informal carers, usually spouses.

3.17 The key factors which makes these schemes successful are the skilled response from a multi-disciplinary team, the flexible and intensive care, and a positive relationship with users.

3.18 We recommend that:

Every local authority area should have in place a comprehensive, joint intensive home support team, by mid 2001-02.

Short Breaks

3.19 Previously known as respite services, we recognise firstly the continuing levels of unmet need. Of an estimated 150,000 carers who provide more than 20 hours a week of care, half have not had a break for more than two days since beginning to care. We also need more effective and personalised short break services — at home - to widen choice as part of a continuum of care. Improving these services is already part of the National Carers’ Strategy, the Learning Disability Review and the Social Justice Report. And almost every policy or strategy document locally recognises that short break services do not meet needs, and are probably not sufficiently flexible or focused. A particular problem is responding effectively to emergencies. Much of the current service is directed to carers’ rather than users’ needs. The term ‘short breaks’, however, applies to both.

3.20 Short breaks should provide choice: of location (either at home or in other settings), and of frequency and duration (weekends or evenings, or in more substantial blocks). To be effective, certain key elements need to be in place. Resources need to be dedicated to short break supports and not to any specific provider, such as a residential care or nursing home. Though emphasising breaks at home, we recognise that some people want or perhaps need a break in a different setting, such as a residential care or nursing home. Users themselves and their carers are often best placed to advise agencies on the criteria for short-break services.

3.21 We cannot realistically resolve these problems overnight. Agencies need therefore to increase incrementally both the level of short break services and the proportion of short breaks available at home. The Group’s thinking, though founded in older people, is translatable across all care groups, and should be interpreted as such.

3.22 We recommend:

Each year, agencies should provide both more short breaks (to reduce the number of carers providing most care, without a break), and more breaks at home.

A Practical Shopping/Domestic/Household Maintenance Service

3.23 A number of studies point to many older people and disabled people being unable to do key daily living activities without assistance. For those living alone or without close natural support this is a particular issue. Alongside that, in some areas of Scotland older people not requiring personal care cannot get assistance with meal preparation, shopping, cleaning or other tasks. These are not daily needs, but are usually intermittent.

3.24 To address these needs we want local authorities to arrange a low intensity, practical shopping/domestic/household maintenance service. It can help older people retain their independence at home and prevent further deterioration; ensure they live in a healthy and safe environment; and reduce potential exclusion. (The service may operate alongside the low intensity advice and support which help people sustain tenancies, funded at present through Housing Benefit and from 2003 under ‘Supporting People’5).

3.25 This service can be provided in a more structured way than under the former home help service. We envisage a new style service with a focused approach, separate from personal care services, and which could be provided by local authorities but more likely through the local voluntary or independent sectors. This is the kind of service we think authorities should charge for. Some places already have these types of service. Again, the issue is making them available consistently across Scotland.

3.26 Changing times offer changing solutions. We live in an electronic age, and agencies need to look at the role of, for example, home delivery of food stuffs, telephone ordering services and, indeed, the Internet.

3.27 We recommend:

Every local authority should identify the need for a practical shopping/domestic/household service, and arrange it comprehensively, by mid 2001/02.

A Service Development Centre for Older People

3.28 We recognise that there is a huge change agenda surrounding older people. It is not just about rebalancing care and improving joint working in areas that affect them, but also in recognising the contribution that older people can make more generally. We considered at length whether or not a dedicated centre should lead and support change, to ensure that older people can in future access better quality services more consistently. On balance, we concluded that a centre was necessary, which our consultation seminars broadly supported.

3.29 A centre for older people’s services would be a focal point for change management, not just for rebalancing care but also more widely, and for advice to those at the ‘coal face’. It would provide a lead on:

• winning the hearts and minds for the change agenda and for its implementation;
• supporting the change agenda by identifying "champions" and enabling them to support and encourage others, and sharing good practice generally;
• addressing quality co-ordination, by helping develop good and consistent quality services;
• promoting older people’s involvement in service planning and delivery;
• supporting the organisational and cultural changes facing staff in a number of agencies;
• developing multi-disciplinary and advanced training for care managers and other professionals across the care spectrum.
• broader issues such as the application of ‘Better Government for Older People’;

3.30 The centre would also become a source of expert advice on service and organisational issues, on good practice and on research and information on older people. It would also have a role in ensuring quality services are in place in hospitals, in the community and in people’s homes by working alongside those responsible for standards and monitoring.

3.31 Without in any sense making direct comparisons, such a centre would perform a similar function to the Scottish Dementia Services Development Centre, the Scottish Development Centre for Mental Health and the proposed Centre for Learning Disabilities. Indeed one of its tasks would be to address interrelated questions with these other sources of expertise.

3.32 Most people recognise the need for a centre; but some are concerned that resources which could be applied to services would be tied up in infrastructure costs. We do not see this as a new structure per se. It could be attached to an existing facility or facilities — almost virtual in its physical presence, but far from it in effect. Costs should not therefore be significant, but the value substantial.

3.33 We therefore recommend:

The Scottish Executive should, in 2001, set up an older people’s service development centre to champion the development of good and innovative community care services, promote training and assist implementation of the Group’s proposals.

Summary

3.34 Older people have not been able to access the services they need to support them at home. We address that. Our proposals to rebalance care for older people require more services focused on care at home. The Framework for Mental Health Services and "The same as you?" do the same for people with mental health problems and learning disabilities respectively.

3.35 Our approach to rebalancing care for older people focuses on putting in place within set timescales 3 key services. Investment in these services — which are flexible, responsive and joint - will strengthen agencies’ ability, together, to care properly for older people in their own homes. To underpin these measures, we recommend new planning/ management systems focusing initially on older people, as set out in Chapter 5. The new national planning and financial framework will identify the collective new resources available for improving services for older people, and set priorities for action locally. And local joint resourcing and joint management of services will improve the way services are organised and delivered on the ground.

3.36 In making these recommendations, we recognise that one size does not fit all. Every area must put in place each service we recommend. But agencies locally will decide for themselves how to organise any particular service to suit their own circumstances. In particular, while urban areas may use the opportunity to employ more specialised staffing, rural areas may look for more multi-skilling and multi-tasking.

3.37 The key services we have identified are already in place in some areas, and have been proven to make a difference. They now need to be available across Scotland, and everyone who needs them should have access to them. The task facing all agencies is to reconfigure their services locally to focus on sustaining people at home. This may not be easy, but some have risen to that challenge and are already doing so successfully. Our combination of measures will enable many more people than at present to be cared for at home — properly and appropriately - and thereby reverse the trend since the community care policy came into being. That is what older people in Scotland want.

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