< Previous | Contents | Next >

Report of the Joint Future Group

CHAPTER 4 JOINT WORKING

4.1 Despite the continuing emphasis on and improvement in joint working since the community care policy was fully implemented in 1993 there remains, as indicated in Chapter 1, a long way to go. We want to use the positive developments in many parts of Scotland to overcome instances of resources not being used to the best effect, of systems and services not delivering for either users or agencies, and of professional skills not being properly utilised. We want to raise standards and achieve greater consistency.

4.2 Many of our proposals for rebalancing care will also improve joint working. Our task on joint working was to identify a set of measures which must be implemented. We may have wanted to do that across the whole of community care but in practice focused on a few key areas where better joint working will make a real difference. The 3 areas are:

• assessment and care management;
• sharing information; and
• equipment and adaptation services.

4.3 They are all at the heart of community care. Assessment and care management and sharing information are key processes which can contribute to effective outcomes. Equipment and adaptation services need modernisation. They have a large user base and a significant effect, but are often marginalised, fragmented or disjointed. Each will be more effective if more joined up.

4.4 Our approach to improving joint working — across all care groups - restores the person to the centre, and uses proven systems and practices, against a backdrop of joint resourcing and joint management of services as set out in Chapter 5.

Assessment and Care Management

A Single, Shared Assessment

4.5 There is widespread acknowledgement that assessment arrange-ments need to improve. Too often people are visited by several different professionals and require to repeat the same basic personal information. And because individual agencies do not accept others’ assessments the whole process is often repeated. The experience in Perth & Kinross, as described in the ‘Patients’ Journey’, of 37 steps in the assessment of an older couple - with the health and social care professionals meeting first at step 25 - illustrates the need to do better. Assessment has to focus on the needs of the person and should be organised to do this efficiently - not to suit professionals or agencies.

4.6 There is also scope to make fuller use of self-assessment for lesser needs, as suggested in Modernising Community Care. Thinking needs to be more about how best to get effective outcomes for people, not about how to get them into systems (sometimes unnecessarily and with limited effect). Reducing unnecessary bureaucracy allows scarce resources to focus on those cases with greatest needs.

4.7 We aim to reduce that bureaucracy and duplication in assessments. We propose that there should be a single, shared assessment. For complex cases, different professionals with special expertise need to contribute (either from a multi-agency team or from a more specialist background). Housing professionals have an important part to play too, especially where housing is an issue. And through local protocols and training, the outcome of the assessment must be accepted by fellow professionals, irrespective of the lead professional. Responsibility for the assessment and ownership of the outcome will therefore be shared.

4.8 We expect single, shared assessments:

• to promote a structured exchange between the user and the assessor about perceived needs, including where relevant the views of informal carers. A separate assessment of the carer’s needs should also be offered.
• to be undertaken by one member of the multi-agency team (the most appropriate lead professional), drawing on contributions from other members of the team as necessary. Contact with the service user for assessment purposes should be through the lead professional. If the assessment points to the need for specialist opinion, this should be sought, building on the basic information already collected.
• to be a passport to the full spectrum of community care services, with no subsequent reassessment necessary unless needs change.
• to include a financial assessment completed by the assessor (which recognises this being an integral part of the assessment).
• to be available to the person, and with their consent the main informal carer, together with the agreed care plan to meet their needs.

4.9 The single, shared assessment creates a single "gateway" or point of entry to the multi-agency team and community care services. It also presents a logical opportunity to seek the explicit consent of the person being assessed to sharing of information between agencies to help them respond holistically and efficiently to need.

4.10 Effective assessments have to be underpinned by an effective assessment tool. Some agencies have or are developing single, shared assessment tools. Further work may, however, be needed to meet our objectives.

4.11 We reviewed the Care Needs Assessment Packages (Carenap) for Dementia (D) and the Elderly (E) and their associated databases. We believe that these tools offer significant promise and with some refinement would meet our vision of a single, shared assessment tool. We understand that the Scottish Executive aims to support that refinement in partnership with the developers, and also enable more systems integration between primary care and local authorities.

4.12 We recommend that:

Agencies locally should have in place single, shared assessment procedures for older people and for those with dementia by October 2001, and for all client groups by April 2002.

Agencies locally should have in place by October 2001, a single shared assessment tool for older people and people with dementia. Local agencies should either adapt existing systems or develop systems to achieve the outcomes specified in the report, or adopt Carenap ‘D’ and ‘E’.

4.13 Our proposals will change markedly both the role of professionals and their participation in assessments. Two steps seem essential - firstly, through joint protocols agencies need to secure agreement locally on the systems for and ownership of assessments; and secondly, to train staff jointly in assessment practice. Putting these in place has to be an early priority.

‘Intensive Care Management’

4.14 Care management was introduced in 1992, but has not developed uniformly. Like many parts of community care, it lacks consistency. It is not always clear who should receive care management; its meaning is interpreted differently; and while in some areas only social workers carry out care management tasks, in others a range of professionals are care managers. A recent conference referred to over 600 models of care management in the United Kingdom.

4.15 There is a need to refocus care management so that it is clear:

• what needs require care management;
• what tasks are involved;
• who carries it out; and
• what skills and knowledge care managers need.

4.16 Our first step is to change the title to reflect its purpose. For the purposes of this report, we suggest "Intensive Care Management". The second is to define its scope. It is for people with complex needs, or frequently or rapidly changing needs.

4.17 Most referrals for community care services can be dealt with by the provision of a straightforward service immediately, or following a brief assessment. To help, a number of screening tools are available (as set out in the 1998 circular6). For more complex cases, intensive care management will co-ordinate and deliver services in a way that is tailored to meet these people’s needs.

4.18 The care manager can be a social worker, community nurse, occupational therapist or other similar professional. In integrated services, professionals lose their label and assume a more corporate role. The key qualities are their skill to judge the person’s and any carer’s needs, the knowledge and skill to secure and co-ordinate the full range of services, the skill to assess and manage inter-personal relationships between the person cared for and the carer; and the ability to manage a devolved budget. Research shows that better results emerge where care managers have devolved budgets - ultimately to individual professionals - and access to a wide range of resources from different services. Care managers need that flexibility if they are to respond to individual circumstances. Concerns about resource management and control of devolved budgets need to be addressed through systems development and training, rather than inhibiting the scope of care managers.

4.19 Local authorities and the health service must provide the organisational framework to support effective care management. We expect care managers to work in a climate of multi-disciplinary, multi-agency teams with joint resources, shared objectives and agreed priorities. Care management also needs to be more user-led; greater use of direct payments could, for example, be one of the results.

4.20 As a consequence of these changes, we envisage individual care managers being responsible for the long-term support of up to 40-45 people at any one time. Broadly speaking, this model of intensive care management parallels that developed in Kent7, which has been evaluated extensively and proven to be successful.

4.21 Some people attending the seminars were concerned that the emphasis on care at home could result in very expensive care packages for older people, and suggested that there should be some form of cost limit. That is clearly not within our remit. But it is a matter for individual authorities to consider.

4.22 To redefine and reinvigorate care management, staff from different agencies will need training. We propose a new initiative to strengthen and develop the skills and knowledge of care managers - on a joint basis. It would be aimed at post-qualifying level, but the underlying concept also needs to be part of qualifying training across the respective professional groups. The outcome would be that only suitably qualified persons would act as intensive care managers.

4.23 We therefore recommend:

The Scottish Executive should redefine care management as ‘Intensive Care Management’ which will be for people with complex or frequently changing needs.

Care managers should be trained in ‘Intensive Care Management’ throughout 2001-2002. Only those who had undertaken such training should carry out ‘Intensive Care Management’.

Information Sharing

4.24 We want to see our thinking on the joint management of services, more joined up assessments, etc. underpinned by a culture of information sharing which, in turn, seizes the opportunities for information systems integration. But we also need to reassure service users that personal information will be treated sensitively and stored securely in accordance with the law.

4.25 To support person-centred services, we need person-centred information systems. They need to extend beyond the starting point of sharing information between mainly statutory agencies in social care and health, to include housing, education, the voluntary sector and the Benefits Agency. That is the intention of e-government generally.

4.26 These issues are heavily influenced at the moment by action nationally. Firstly, the NHS Programme Information Management & Technology Board will take the lead in developing a strategic overview on how modern technologies can support community care services. It will report by October 2001.

4.27 Secondly, the Confidentiality and Security Advisory Group for Scotland (CSAGS) will take the lead in specifying the principles for information sharing to be incorporated in agencies’ local protocols, to meet the requirements of the Data Protection Act (1998). It will report by April 2001.

4.28 Thirdly, the Social Work Information Review Group (SWIRG) will take the lead in identifying the information needs for community care, and its exchange. It expects to report by mid-2002.

4.29 In its short life, the Joint Future Group has been successful in ensuring that the separate health and social work information developments under the Programme Board and SWIRG respectively now cut across the wider community care information spectrum and take account of e-government’s focus on the citizen, not agencies.

4.30 At a local level, while the developments above will bring their influence to bear in due course, enabling the transfer of information about a user by obtaining their consent must be an integral part of the assessment tool described earlier in this Chapter. This approach can indeed be implemented now, through specific agreement with the user.

4.31 We therefore recommend:

The Scottish Executive should, by 2002, offer a strategic lead on the development of community care information, information sharing and systems integration.

Locally, the arrangements for single, shared assessments should include specific proposals for the necessary sharing of information between agencies, by obtaining explicit client approval.

Equipment and Adaptation Services

4.32 Equipment and adaptation services can make a very positive impact if they are organised and managed effectively. Demand in this area represents 25-45% of all referrals to social work departments, and adaptations are also a significant part of the work of housing agencies. We benefited from a detailed analysis of the problems facing equipment and adaptation services and their users. Our generic recommendation below is underpinned by a series of specific measures to achieve the desired outcomes. Our starting point was obviously joint working but our interest spread to related issues such as the role of occupational therapists who currently carry out most of the work in this area.

4.33 We recommend:

To modernise and improve equipment and adaptation services, the Scottish Executive should establish a strategic overview, and set out a programme of change that will require agencies locally to integrate equipment and adaptation services with the rest of community care services, and put in place a number of specific measures that will result in a better-focused and more effective service for the user.

Strategic Direction

4.34 To give equipment and adaptation services a much needed sense of direction we believe it is necessary to set up a national Strategy Forum — not necessarily a permanent feature — to be led by the Scottish Executive but with its membership drawn from leading players and users. It will review existing services and how they interact, develop a programme for change that will identify minimum service standards for information and self selection of equipment, and suggest research on the effectiveness of equipment and adaptation services. The Scottish Executive should set up a Strategy Forum by the end of January 2001.

Informed Choices

4.35 One of the weaknesses in equipment and adaptations services is a lack of good and accessible information for both potential service users and for professionals. We see this being addressed in 3 inter-related, ways:

• Firstly, local agencies need to produce information for the public on existing equipment and adaptation services, by June 2001. This can be in the form of booklets but could also use the opportunities afforded by IT.
• Secondly, the Strategy Forum will produce guidelines on core information requirements for service users and assessors, by Autumn 2001.
• Thirdly, we need local advice and demonstration services to help people make better choices by having a much better understanding of what is available and being able to try out potential solutions. A few facilities already exist, usually in the form of Disabled Living Centres, but a range of flexible and innovative services will be needed across Scotland. They can be developed in tandem with IT solutions or existing facilities such as one stop shops, healthy living centres, etc. In rural areas they may need to be mobile. The Strategy Forum will provide a lead. Local agencies should put these services in place, in response to the Forum’s guidance, across Scotland by April 2002.

Joint Equipment and Adaptation Services

4.36 Developing more joined up services will be helped considerably by our recommendations in Chapter 5 on joint resourcing and joint service management. A joint approach will increase access across the often artificial boundaries between equipment and adaptations funded and supplied by the NHS, local authorities (social work or housing) or other agencies. It should also improve the efficiency and cost effectiveness of procurement, storage and distribution, and enable better access to stock through IT networks and other systems. Alongside these structural changes, we need to encourage recycling of equipment no longer required.

4.37 North Lanarkshire Council reviewed its adaptation services between social work and housing in 1996. Many authorities across Scotland have used the resultant practice document. East Ayrshire Council has taken this further and developed a detailed service specification on work quality, timescales for completion and providing information to users, all with built-in penalties for default. These more specific purchasing criteria resulted in twice as many adaptations for half the cost. From a joint resourcing perspective, the housing department also transferred its adaptation budget to the social work department.

4.38 Agencies should jointly resource and jointly manage equipment and adaptation services, by April 2002, and should consider the benefits or combined storage facilities as soon as possible thereafter.

4.39 We were impressed by the contribution of care and repair schemes to sustaining people in their own homes, and welcome the commitment nationally to establish care and repair schemes in all areas of Scotland. But we also saw a need for agencies to be better informed of the level of adapted properties in their area (on which Scottish Homes issued guidance in 1999); for, in the light of initiatives on common housing registers, a single point of access to housing services; and for greater consistency in the allocation of tenancies.

4.40 All local authorities should create, with their partners, (Scottish Homes, registered social landlords and the private sector) registers of adapted properties, by mid-2002.

4.41 The partner agencies (local authorities, Scottish Homes and registered social landlords) should have one point of contact for applications and a more joint approach to allocations through consistent and shared allocation arrangements, by 2002.

Simple Solutions

4.42 We want to reduce inefficiencies and improve user choice by enabling users to decide for themselves on ‘simple’ equipment and adaptations. A number of studies show this is feasible and effective, if good information and advice is available. This is obviously related to our proposals in that field.

4.43 Unqualified staff already offer advice on "simple" solutions under the guidance of qualified occupational therapists. Other staff could do this if appropriately trained in disability awareness, equipment and adaptation options, and sources of information, advice and demonstration.

4.44 The Strategy Forum is to draw up guidance on self-selection arrangements, and for training of staff, with the training itself co-ordinated by the proposed Centre for Older People (Chapter 3). Thereafter, local agencies should put in place, by Autumn 2002 self-selection arrangements for "simple" solutions and training of staff by 2002/03.

Occupational Therapy Services

4.45 Proposals for joining up and improving equipment and adaptation services will inevitably impact on the work of occupational therapists. As demand for equipment and adaptations grows they are often seen as rationers of a limited resource. And inflexible organisational boundaries can mean both hospital-based and local authority occupational therapists being involved in one case. There are also questions about how the occupational therapy service should be organised, in the context of more joined-up health and social care services, to maximise the use of occupational therapy skills and enable other workers, qualified or otherwise, to play their part in providing equipment and adaptation services.

Using Occupational Therapists More Effectively

4.46 We recognise the need to change the role of occupational therapists so that they are not seen as the sole route to equipment and adaptations. Rather they should contribute to care solutions more generally by training and supporting others in managing "simple" solutions, developing complex packages of equipment and adaptations, and becoming more widely involved in intensive care management. They should have a pivotal and equal role in joint, co-ordinated hospital discharge arrangements; and be an integral part of intensive support services and multi-disciplinary community-based rehabilitation services (as indicated in Chapter 3).

4.47 Studies in Nottingham (McCloughry & Murphy 1998) show that 12 out of a sample of 21 people identified by social workers as requiring residential care were able to remain at home following occupational therapy intervention. And of 56 people receiving home care, half did not require the level of service being received when assessed by an occupational therapist (McCloughry & Lowe, quoted by DOH 1999).

Organising Occupational Therapy Services

4.48 Current demarcations between ‘health’ and ‘social care’ occupational therapists are not helpful. There is a logical progression from accessing one another’s services across organisational boundaries, to integrating certain services or parts of them (for example hospital discharge teams), and potentially to full service integration.

4.49 We recommend a staged approach. Firstly maximising co-ordination in community care services and then moving towards an integrated occupational therapy service within the wider context of the agenda for joined up and multidisciplinary health, housing and social care services.

4.50 Pointers to achieving these goals include commonality of boundaries, the right mix of specialist and generic skills, addressing issues related to pay and conditions and professional development and accountability, and consideration of the wider change agenda in community care.

4.51 We recommend:

To target occupational therapy services more effectively, agencies need to modernise equipment and adaptation services, and to remove duplication between hospital and community based occupational therapy services wherever practical. For community care services that reoganisation needs to begin as soon as possible, followed by the rest of health and social care within the context of the wider agenda for joined up health, housing and social care services.

Summary

4.52 This chapter sets out in some detail our proposals to improve joint working. They apply to all care groups. We have focused our attention on 3 important areas where improvement is clearly possible. The measures we propose are, as said elsewhere, of proven standing and testimony to those who have already addressed change. There will be organisational benefits for health, social work and housing services from more streamlined systems, more joint involvement and ownership of systems and, in the case of equipment and adaptation services, a much needed joint approach to service organisation and delivery. But the ultimate goal is the positive effect on users of changes at the heart of community care. They should notice a real difference as a result of our proposals. Putting them in place must be a priority.

< Previous | Contents | Next >