Living Well In Later Life (Full Report) - NHS Wales• living well in later life • leading organisations through change In addition to these themes, the local inspections focused

Living well in later lifeA review of progress against the National ServiceFramework for Older People

March 2006

First published March 2006

© 2006 Commission for Healthcare Audit and Inspection

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1A review of progress against the National Service Framework for Older People

The Healthcare CommissionThe Healthcare Commission exists to promote improvements in the quality of healthcare andpublic health in England and Wales. In England, we are responsible for assessing and reportingon the performance of both the NHS and independent healthcare organisations, to ensure thatthey are providing a high standard of care. We also encourage providers to continually improvetheir services and the way they work.Website: www.healthcarecommission.org.uk

The Audit CommissionThe Audit Commission is an independent public body. It appoints auditors in the areas of localgovernment, housing, health and criminal justice services and quality assures auditors’ workunder the Code of Audit Practice. The Commission seeks to drive improvement in public servicesthrough effective audit and inspection, and by promoting good practice through a programme ofnational studies (which in health focuses on financial management).Website: www.audit-commission.gov.uk

The Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection is the single inspectorate forsocial care in England, responsible for regulating all social care providers, whether in the publicor independent sector. The Commission was created by the Health and Social Care (CommunityHealth and Standards) Act 2003. The Commission's primary aim is to promote improvements insocial care by putting the needs of people who use care services first.Website: www.csci.org.uk

2 A review of progress against the National Service Framework for Older People

Contents

Executive summary 3

Introduction 16• the approach 19• involving others in the review 21• standards and themes 21

Tackling ageism and promoting equality 23

Involving older people 31

Designing and delivering services around older people 36

Stroke 52

Falls 56

Mental health 60

Living well in later life 64

Leading organisations through change 72

Conclusions 81

Challenges and recommendations 87

Moving forward 93

References 99

Appendices 101

Appendix A: Meetings with key stakeholders 101

Appendix B: Policy changes and influence since the national service framework 102


Executive summary

Society today has changed greatly in the last20 years and as a result our idea of old agehas changed. As the current debate onpensions highlights, we can expect to livelonger, but, more than that, we expect to beable to continue to live active lives.

The UK has an ageing population. There is ahigher proportion of older people in thecommunity than ever before. A century agoonly one in 20 people were over 65, today onein six are over 65. It is expected that, by 2051, a quarter of the population will be over 65(Office for National Statistics, census data).While the expectations of older people arechanging, the impact of these expectations onsociety are growing. An ageing population putspressure on health and social care services,but it also places demands on other servicessuch as transport, leisure and housing.

The National Service Framework (NSF) forOlder People sets national standards toensure that services of a high quality areavailable to all older people. Since theimplementation of the national serviceframework (NSF) there have been significantdevelopments in Government policy including:Opportunity age – meeting the challenges ofageing in the 21st century, a strategy by theGovernment on how to meet the needs of anageing population, published in March 2005and Independence, wellbeing and choice: Ourvision for the future of social care for adults inEngland, the Department of Health’s greenpaper, published in March 2005. This papersets out a vision for social care for adults overthe next 10 to 15 years and outlines how thismight be realised. The changes in policy alsoinclude the publication in January 2006 of Ourhealth, our care, our say: a new direction for

community services, the Government’s whitepaper, which sets a new direction for thewhole health and social care system. Thewhite paper confirms the vision set out inIndependence, wellbeing and choice and callsfor a radical and sustained shift in the way inwhich services are delivered, ensuring thatthey are more personalised and that they fitinto the busy lives people have.

The Healthcare Commission, the Commissionfor Social Care Inspection (CSCI) and theAudit Commission have worked inpartnership to assess the progress of theNHS and local authorities in meeting thestandards set out in the NSF, taking intoaccount other developments in policy sincethe NSF and the impact these have had onthe lives of older people.

By working together, the three commissionswere able to build a picture of the wholesystem of services that older people use fromcare services to services that contributetowards wellbeing and quality of life. A wholesystem is a concept that describes howservices are organised around the person thatuses them and the interdependence of oneservice upon another.

This is the first collaborative in depth reviewcarried out by the three commissions. Thisjoined up approach to inspection enabled us tomake an assessment of services provided bythe NHS and local authorities across ageographical area and the extent to which theyworked together as a well coordinated, wholesystem to improve the lives of local people.

This report provides a national snapshot of thestate of services for older people at the time



of the review. It offers an opportunity to reviewwhat has already been achieved and establishwhat else needs to be done to ensure thatstandards are met and that services for olderpeople continue to improve.

The scope of the review was broad, reflectingthe enormous diversity within this group ofpeople and their wide range of needs,interests and aspirations. This group includesthe generations that felt the impact of the twoworld wars through to the baby boomers whoare now in their 50s and 60s. For thesereasons, any response to providing services,including care and support, needs to beindividually tailored to the needs andaspirations of individuals. The review,therefore, had a strong focus on designing anddelivering services around older people, andon the importance of working in partnershipto achieve a flexible and holistic response.

In line with the NSF, an extensive part of thereview focused on care and support services.Only about 15% of older people are in regularcontact with care services at any one time, butthis is a group who have not always receivedthe best possible support. In comparison, theyare significant users of healthcare services.Although people aged 65 and over make uponly 16% of the population, they occupyalmost two thirds of general and acutehospital beds and account for 50% of therecent growth in emergency admissions.

The NHS spent around £16 billion on peopleover the age of 65 in 2003/2004, accounting for43% of the total NHS budget. In the same yearsocial services spent around £7 billion, whichwas 44% of their total social services budget.

A good quality service is judged on whether itis economical and provides value for money aswell as by the experiences of the people whouse the service. An important part of thisreview is to ensure that these significantfinancial and other resources, are best used toprovide real choices and better outcomes forolder people and to help address some of thehuge pressures the service faces.

Most older people will make very little use ofcare services, so the local inspections carriedout as part of this review were broad enough toinclude the many issues that matter to allolder people, from leisure and learning totransport and safety in the community. Eventhose older people who do require helpfrequently receive a response that focusessolely on their care needs at a time of crisis,rather than the many responses that givemeaning to life such as being involved in theirlocal community. This review focused onservices used by people from the age of 50,reflecting the important contribution that ahealthy midlife can make towards achieving anactive, fulfilled later life.

The review

The evidence for this review was collectedfrom a number of sources, includinginspections of services for older people in 10communities in England.

A local community includes health and localauthority services within a definedgeographical area. Inspection teams, made upof staff from the three commissions, inspected40 NHS trusts and 10 local authorities inEngland. An important element of the

Executive summary continued


inspections was research and discussion witholder people on their views of local services,through surveys, focus groups and events.

The NSF has eight standards and each of thesestandards has a relationship to the others withconsistent themes running throughout theNSF. As a result, five cross cutting themeswere identified. These themes were then usedto get a more complete overview of the impactof the NSF on the lives of older people, takinginto account developments in policy since theNSF and the views of older people aboutservices. These cross cutting themes were:

• tackling ageism and promoting equality

• involving older people

• designing and delivering services aroundolder people

• living well in later life

• leading organisations through change

In addition to these themes, the localinspections focused on the three conditionsincluded in the national service framework –stroke, falls and mental health. These conditions were used to get a view ofthe progress that has been made against all of the standards in the NSF.

This report consequently provides a nationalassessment of progress in health and socialcare services for older people using thefindings from the local inspections togetherwith other evidence and research.

Key findings

The National Service Framework for OlderPeople is a 10 year programme. This reportcomes at a mid point in that programme and shows that while there has been somesignificant progress, further action is requiredin three key areas, without which sustainableimprovement in the experiences of olderpeople of public services is unlikely to beachieved. Three key areas are:

• Tackling discrimination through ageistattitudes and an increased awareness ofother diversity issues.

• Ensuring all of the standards in the NSF aremet including further guidance on the nextsteps in implementing the NSF from theDepartment of Health due to be publishedin April 2006.

• Strengthening working in partnership betweenall the agencies that provide services forolder people to ensure that they worktogether to improve the experiences of olderpeople who use services.

Tackling discrimination

Explicit age discrimination has declined sincethe NSF was published as a result of NHS trustsauditing policies on access to services andsocial services reviewing their criteria for

The 10 local communities inspected were:

Buckinghamshire LeicesterBrent DorsetLiverpool PortsmouthRedcar and Cleveland Wiltshire


eligibility. These are the criteria a local authorityuses to prioritise who receives social careservices. Access to cardiac procedures and hipand knee replacements have improved sincethe NSF was published. Between 1999 and 2004the number of hip replacements carried out onpeople aged between 65 and 74 increased by39%, and for people 75 years and older, itincreased by 22%. According to hospital episodestatistics from the Department of Health, therehas been a general increase in hip and kneereplacements for the whole population but theincrease is still significant for older people. The exception to this decline in explicitdiscrimination is mental health services wherethe organisational division between mentalhealth services for adults of working age andolder people has resulted in the developmentof an unfair system, as the range of servicesavailable differs for each of these groups. Forexample out-of-hours services for psychiatricadvice and crisis management for older peopleare not as developed as those for adults ofworking age. Older people who have made thetransition between these services when theyreached 65 have said that there were noticeabledifferences in the quality and range of servicesavailable.

Despite these changes there is still evidence ofageism across all services. This ranges frompatronising and thoughtless treatment fromstaff, to the failure of some mainstream publicservices such as transport, to take the needsand aspirations of older people seriously. Manyolder people find it difficult to challenge ageistattitudes and their reluctance to complain canoften mean that nothing changes.

We found that some older people experiencedpoor standards of care on general hospital

wards, including poorly managed dischargesfrom hospitals, being repeatedly moved fromone ward to another for non-clinical reasons,being cared for in mixed-sex bays or wardsand having their meals taken away before theycould eat them due to a lack of support atmeal times. All users of health and social careservices need to be treated with dignity andrespect. However, some older people can beparticularly vulnerable and it is essential thatextra attention is given to making sure thatgivers of care treat them with dignity at alltimes and in all situations. To fail to do this isan infringement of their human rights.

There is a deep rooted cultural attitude toageing, where older people are often presentedas incapable and dependent – particularly inthe media. As there is an increasingly ageingpopulation, there is a need for policy makersand those who plan and deliver public servicesto consider the impact of ageism and to takeaction to address this.

During our inspections of local communities,we also found that awareness of diversityissues was at an early stage of development,with more work required to ensure that olderpeople from black and minority ethnic groupsreceive services that are culturally sensitiveand responsive to their needs. The high levelsof morbidity and mortality from certaindiseases and the difficulties of access andappropriate and responsive services havebeen documented well in relation to black andminority ethnic groups. There is a need toimprove information and communityengagement and to have detailed informationabout the needs of the population whenplanning services. Appropriate steps shouldbe taken to form partnerships with the local


black and minority ethnic groups representingolder people, to ensure that this group ofolder people is fully engaged in the planningand development of services. Organisationswhich commission or provide health andsocial care should take account of diversity inall they do, take account of cultural andreligious needs and embed this understandinginto mainstream services for older people.

Sadly there are occasions when older peopleexperience abuse and neglect by the peoplewho are supposed to be caring for them. It isimportant that this risk is minimised. This canbe done by care staff being aware of how andwhen abuse and neglect could occur and bytaking action if this is identified. We found thatthe arrangements for safeguarding olderpeople operated effectively in most areas andthere were multi-agency policies andprocedures. However, there is still room forimprovement. It is vital that health and socialcare organisations continue to address thisissue to ensure that opportunities for abuseand neglect are minimised and, when they aredetected, that they are acted upon.

Standards set out in the nationalservice framework

The National Service Framework for OlderPeople and the developments in policy thathave followed have placed an unprecedentedfocus on services used by older people. Theinspections found a great deal of activity toimprove the experiences of older people ofpublic services. Staff in partner organisationswere working together to establish newinitiatives and new ways of working to do this.There has been progress in a number of areas.

Explicit age discrimination in access toservices has been addressed by most healthand social care services. All of thecommunities inspected as part of this reviewhad made a significant effort to ensure thatpolicies and criteria for eligibility did notdiscriminate against older people. The AuditCommission’s review on national progressagainst the NHS plan in 2003 found that 76%of NHS trusts had reviewed their criteria foreligibility to services as required by the NSF.

More good quality care than ever before isavailable to people who have had a stroke. All ofthe general hospitals caring for people whohave had a stroke in the communities inspectedprovided a specialist stroke service, whichoperated according to the clinical guidelines forbest practice approved by the Royal College ofPhysicians. Seven of the 10 communitiesinspected also had a stroke unit. The Nationalsentinel stroke audit carried out by the RoyalCollege of Physicians in 2004, and published inMarch 2005, showed that 82% of hospitals inEngland have a stroke unit and more peoplewere treated in such a unit for part of theirhospital stay than in the previous year.

The number of older people who have had flu vaccinations has increased. There hasbeen a 2% increase in people over 65 beingvaccinated against flu between 2002 and 2004.

The number of older people who have stopped smoking has increased. All of thecommunities inspected could demonstrate anincrease in the number of people over 60 whohad stopped smoking. This is in keeping withnational trends which show the number ofpeople aged 60 and over who set a quit date tostop smoking increased by 113.8% between



2001 and 2005, and of those who set a quitdate and were successful there was anincrease of 5% for the same period.

More people are being supported to live at home. Health and social care services inthe communities that were inspected as partof this review were able to demonstrate thatthey were continuing to move towardssupporting older people who are frailer to liveat home independently. There was also areduction in the number of older peopleadmitted to care homes. This matches thenational picture, which shows that the numberof households receiving intensive home careper 1,000 of the population aged 65 and over,has steadily increased from eight to 11between 1998 and 2004 (Department of HealthPerformance and Assessment Frameworkdata 2005).

All of the communities inspected coulddemonstrate a reduction in delayeddischarges from hospital over the past twoyears. The Department of Health’s statisticsshow that there has been a 67% reduction indelayed transfers of care from 5,396 in 2001 to just 1,804 in 2005.

There is a growing interest in the widerwellbeing of older people, with services suchas leisure and culture playing an increasinglyimportant role, and strategic partnershipsspearheading some innovative partnershipdevelopments.

The National Service Framework for OlderPeople has led to some positive achievementsbut there is further work to do to meet thestandards set out in the NSF. The key issuesidentified as a result of this review that need

further action are detailed below:

• The full implementation of the singleassessment process across health andlocal authority partners. Older peopleshould have a copy of their assessmentand a personal care plan.

• A change in culture is required, movingaway from services being service-led tobeing person centred, so that older peoplehave a central role not only in designingtheir care with the combination and type ofservice that most suits them, but also inplanning the range of services that areavailable to all older people.

• All aspects of mental health services forolder people need to improve includingperson-centred care, age equality inaccess to the range of services available,treating people with dignity and respect,holistic care in mainstream services and awhole systems approach to thecommissioning of integrated mentalhealth services for older people.

• Integrated falls services are at an earlystage of development and more work isneeded for them to progress further in linewith the five components of an integratedfalls service as set out by the Departmentof Health.

• The management of medicines needs to be addressed, as many older people takingmore than four medications are still notreceiving a review every six months.

NHS trusts and local authorities need to worktogether to ensure that they are reviewing theirprogress against the NSF as part of aframework for managing performance.

Supportive and palliative care, underpinned byservices that are person centred, promotephysical, psychological and spiritualwellbeing. The NSF outlines personal andprofessional behaviours which are consideredparticularly important to end of life care.Services that are needed to promote dignifiedand effective end of life care are complex,requiring good coordination betweenorganisations. They must appear seamless tousers and carers, be easy to access and betotally reliable. We found that the provision ofservices for people at the end of their life wasinconsistent, with integrated systems thatwere developed well in some areas but withroom for improvement in others. The provisionof out-of-hours support was patchy and a lackof practical support may mean some peoplehave to be admitted to a hospital or hospice atthe end of their life when they may havepreferred to die at home.

Strengthening working in partnership

There are examples of some excellentworking in partnership both at a strategic andoperational level. However, only a few of thecommunities inspected had a shared sense of what they wanted to achieve with and forolder people, or how progress would bemeasured. This lack of a clear directionresulted in fragmented services thatconfused people who tried to access them.The range of services that was availablediffered significantly between communitiesand even within a single community.

Sustainable change cannot take place unlessall partner organisations have a shared view ofthe direction in which they want to move, and

how they plan to get there. Earlier researchfrom the Audit Commission has shown thatthis shared vision has a powerful role to play ifit is rooted in the views of older people. Whenolder people are asked about the priorities thatwould most improve their lives, these oftenrelate to issues beyond health and social careservices, such as having a neighbourhood thatis safe, access to transport, an adequateincome and opportunities to meet with others.Therefore visions and strategies for olderpeople must reflect these needs.

A lack of shared direction results in a poor useof resources and in a commissioning processthat does not encourage change. It also resultsin the provision of an inconsistent anduncoordinated range of services.There was evidence of some engagement witholder people but they were not involvedsystematically in the design of services, norwere services tailored to their needs andaspirations. Health organisations and localauthorities were not always effective inengaging with black and minority ethnicgroups and with other older people whosevoices are seldom heard.

While we found that some communities wereimplementing the NSF in innovative ways, thesewere not consistently available to older people,nor was learning from these initiatives sharedor implemented more widely. Only if partnerorganisations work together to agree a sharedvision and to map out a pathway to achieve thisvision, will older people be able to experienceservices that are well planned and joined up.New initiatives from the Department for Workand Pensions, the Department of Health andthe Social Exclusion Unit that aim to testintegrated responses to older people, as well as




learning from the results of the SureStartinitiative for children, will offer usefulexperience on which to build.

Most of the communities we inspected had ajoint workforce development strategy. Workforceplanning was fragmented and opportunities forjoint training, building capacity and thedevelopment of new ways of working, such asgeneric health and social care workers, were notbeing used widely. A few of the communitieswere developing the health and social careassistant role but this was not widespread.Some organisations were experiencingsignificant difficulties in recruitment. The lack ofa joint approach contributed to more problems.

Recommendations


1. While progress has been made by healthand local authorities in systematicallytackling age discrimination, throughaudits of policy, and the reviewing ofeligibility criteria, there is still evidence ofage discrimination and ageist attitudeswhich have an impact on the lives of olderpeople. These include the discriminationolder people sometimes experience whencare services fail to treat them withdignity and respect. Managers of NHStrusts, social services and providers ofindependent health and social care needto ensure that the human rights of olderpeople are upheld at all times.

2. The needs of older people, including thosefrom black and minority ethnic groups, arenot always recognised. NHS trusts, local

authorities and providers of independenthealth and social care, need to ensure thatall staff receive full and ongoing training ondiversity issues, including attitudes toageing, so that older people are treated withrespect. They should respect diversity in allthat they do, taking account of cultural andreligious needs, and embed thisunderstanding into mainstream services.

3. Progress has been made in establishingadult protection committees with anincreased awareness in healthcareorganisations and local authorities of theneed to safeguard older people. However,there is more to be done. NHS trusts, socialservices and providers of independenthealth and social care need to:• review the operation of adult protection

committees

• promote effective working in partnership

• ensure that information is comprehensive

• ensure that the management ofperformance is effective

• implement policies and proceduresthrough training that are easily accessible

Meeting the standards set out in thenational service framework

4. The National Service Framework for OlderPeople provides a 10 year programme forthe improvement of services for olderpeople. Good progress has been made insome areas. However, a number of thestandards have not been met within thetimescales of the NSF. NHS trusts andlocal authorities need to take action to


ensure that the standards set out in theNSF for older people are met, includingthe Next steps update due to be publishedin April 2006 and the Department ofHealth’s Older people mental health servicedevelopment guide.

5. Wherever possible older people aresupported to receive end of life care in theplace in which they choose to die. However,sometimes a lack of appropriate communityservices means that they have to beadmitted to hospital. There is a need forpartner agencies to use the best practicemodels of end of life care to ensure thatolder people and their carers receive promptaccess to well coordinated and effective careand respect at the end of their lives.

Strengthening working in a partnership

6. The effectiveness of partnershiparrangements for services for older peopleis improving. However, partner organisationsshould ensure that partnerships have robustgovernance arrangements with clear lines ofaccountability in line with the LocalGovernment Act 2000.

The Act places a duty on every localauthority to prepare a strategy for thecommunity to link all their strategic plansand to manage partnerships through a localstrategic partnership. Strategicpartnerships working for and with olderpeople should include all the organisationsthat commission and provide services usedby older people as well as older peoplethemselves. This review has demonstratedthe importance of a joined up approach to

planning, commissioning and deliveringservices that takes account of all of thethings that are important to the health andwellbeing of older people. Older peoplehave an important contribution to make inthe shaping of services to ensure that theyrespond to their needs and aspirations.Providers of independent health and socialcare are also important partners within thestrategic partnership, as they bringinnovation and the potential to provideadditional resources.

7. There has been some progress inpromoting health and wellbeing for olderpeople but this has not been the result ofa joint strategy with a coordinatedapproach across health and localgovernment. NHS trusts, local authoritiesand providers of independent health andsocial care need to work together todevelop the promotion of good health andwellbeing. The Department of Health’swhite paper Our health, our care, our say,published in January 2006, has reinforcedthe role of the director of adult social care,working with the director of public health,in undertaking regular joint reviews of thelocal health needs.

8. Partner organisations are working togetherto develop a shared vision for services forolder people. However, organisationalchange has slowed down progress in takingthis forward, partly as a result of healthpolicy, Shifting the balance of power,published in 2001, which changed the rolesof health authorities and PCTs. There is aneed for partner organisations to translatethe shared vision into a shared strategy forservices for older people and to use this to



inform joint commissioning. This shouldresult in a comprehensive and coordinatedrange of services to meet the needs of thelocal population.

9. Partner organisations are engaging witholder people. However, there is nosystematic and coordinated approach tomake the best use of resources. Partnerorganisations need to work together toensure that there is a systematic andcoordinated approach to engagement thatrecognises the diversity of the populationbeing served.

10. Some partner organisations are workingtogether to tackle recruitment andretention of staff. However, many do notand so they are targeting the same smallpool of staff and creating unhelpfulcompetition in the employment market.NHS trusts and local authorities need towork together to develop joint workforcestrategies to become more effective inrecruitment and retention across healthand social care services.

Further work for central Government

Some of the progress needed to improveservices used by older people can only comeabout through support from centralGovernment, particularly in three areas. These are:

1. Following on from Opportunity age, theGovernment needs to develop a crossGovernment national programme of workto help shape a more positive culture onattitudes to ageing.

2. National standards and measures forimprovement have supported theimprovement of performance managementby health and local authorities. However,the performance of individualorganisations in achieving national targetssometimes conflicts with improving theoutcomes for older people across a wholesystem of care. For example, therequirement for acute hospital trusts toreduce waiting times for elective (planned)surgery has resulted in PCTscommissioning a disproportionate amountof acute hospital services compared tocommunity services that could preventemergency admissions to hospital. TheDepartment of Health’s white paper Ourhealth, our care, our say makes acommitment to align how health and localauthorities are being assessed on theirperformance. This should include thedevelopment of ways to measure outcomesfor older people based on the performanceof all partners working together.

3. Older people would particularly like to seeimproved access to podiatry and generalfoot care. Poor foot care can lead to poormobility and result both in a loss ofindependence and in social isolation. TheDepartment of Health could supportimproved access to good quality podiatryand general foot care services by requiringPCTs to commission adequate provision ofthese services.


Further work for the HealthcareCommission, the Commission for Social Care Inspection and the Audit Commission

As well as recommendations for theorganisations that provide services for olderpeople and central Government, it is alsoimportant that the Healthcare Commission,the Commission for Social Care Inspectionand the Audit Commission take action toensure that there is continuous improvementof services for older people and themomentum from this review is continued.

Developing policies and tools at a nationallevel, which will help to support the localimplementation of the National ServiceFramework for Older People, is essential. The Healthcare Commission, the Commissionfor Social Care Inspection and the AuditCommission, as the regulatory bodies withresponsibilities for assessment acrosshealthcare, social care and local governmentwill be taking the following actions, inconsultation with partner organisations.

1. The Commission for Social CareInspection will monitor progress againstthe recommendations in this reportthrough the annual assessment ofcouncils and the inspections of socialservices for older people.

2. The Audit Commission will monitorprogress against the recommendations in this report through the older people’sstrand of corporate assessment, which is part of the Audit Commission’scomprehensive performance assessmentof local authorities.

3. As part of the Healthcare Commission’sannual assessment of performance of NHStrusts – the annual health check – theHealthcare Commission will continue tomonitor progress against key nationaltargets, for example those relating tosupporting older people to liveindependently at home. The requirement totreat all patients with dignity and respectwill be assessed as part of the annualhealth check against the Department ofHealth’s core standard on patient focus.The requirement to take the views of olderpeople and their carers into account indesigning, planning, delivering andimproving healthcare services will also beassessed by the Healthcare Commissionagainst the Department of Health’sstandard on accessible and responsivecare, as will access to services.

4. The three commissions will developimprovement activities targeted at issuesidentified by this review. This includesdeveloping and delivering a jointCommission for Social Care Inspection/Healthcare Commission review of mentalhealth services for older people.

5. Joint indicators will be developed tosupport improvement in key areas,including those areas where progress hasbeen the slowest. These indicators willform part of the ongoing assessment ofhealth and social care organisations andwill be used to look at how services areimproving year on year. The indicators willbe developed in line with broaderframeworks for assessing performancewhich are focussed on outcomes asoutlined in the Government’s white paper



Our health, our care, our say and will beused to underpin improved partnershipworking through the future development oflocal area agreements.

6. The Healthcare Commission currentlysupports a programme of national clinicalaudits. Audit projects aimed at improvingthe quality of clinical care and improvingoutcomes in services for older people willcontinue to be reflected in this programme– which currently includes audits ofservices for people who have had a stroke,services for people who have fallen andservices for people with incontinence.


Introduction

“Services are getting better – gracious, yes. It’s easier to findsomeone to come and help you.”


The Healthcare Commission, the Commissionfor Social Care Inspection (CSCI) and the AuditCommission have worked together to carry outa review of the progress of the NHS, localauthorities and other partners in meeting thestandards set out in the National ServiceFramework for Older People, taking intoaccount other developments in Governmentpolicy since the national service framework(NSF) and the impact this has had on the livesof older people.

This report highlights the findings andactions that are needed as a result of thereview. It takes health, social care and wellbeing issues as its starting point –specifically the Department of Health’sNational Service Framework for Older People1

– but it casts its net wider to examine howwell a wide range of services take account ofthe needs of older people. Older peoplethemselves have played a big part in thisreport and their concerns and interests arereflected throughout the document.

A wide range of research is available whichprovides consistent messages about whatolder people say is important to them in termsof their health, general wellbeing, quality oflife and what they expect from public services.The messages echo those raised by the olderpeople who contributed to this review.

The Audit Commission and Better Governmentfor Older People, an organisation set up byGovernment to encourage local authorities to

engage more actively with older people andimprove services for them, found a number ofstrong themes that ran through much of theexisting research on the priorities of olderpeople. These were:

• making a contribution, and being seen as avaluable member of the community(sometimes referred to as ‘interdependence’)

• tackling ageism and having a voice

• services that are well coordinated, orjoined up

• a comfortable, suitable home

• a safe neighbourhood that has all the mostimportant amenities

• getting out and about

• having useful, enjoyable ways of spendingtime – relationships, social networks,leisure and learning

• a decent income

• information about what is available

• keeping healthy, and having access to goodquality care services if they are needed

This broader view of ageing and older people isevident in many of the local developments thatillustrate this report as well as in national policyinitiatives such as the Government’s whitepaper, Our health, our care, our say2, in theGovernment’s Opportunity age strategy3, and theGovernment’s green paper, Independence,wellbeing and choice4. Also the consultationprocesses that support these – both of whichare highlighted in appendix B, alongside anumber of other key developments in policyhave appeared since the publication of the NSF.

“Without back up, our horizonsare very limited.”

The National Service Framework for OlderPeople was published in March 2001 as a 10 year programme of action and reform. It sets standards for improving health, socialcare and other services in order to improvethe experiences of older people of services in England. It was produced because therewas a growing recognition that, despite manyachievements, too often services failed olderpeople, so the goal of the NSF was to initiatesignificant improvement. The NSF washeralded as the first ever comprehensivenational framework to ensure fair, high qualityand integrated services for older people.

The purpose of this report is to summarise thefindings of 10 joint inspections of services forolder people that were carried out acrossEngland in 2005 by the HealthcareCommission, the CSCI and the AuditCommission. These inspections formed thecentral part of a review of the impact of theNational Service Framework for Older People,commissioned by the Department of Health.The report offers a national snapshot of thestate of services for older people at the time ofthe review. It also sets out recommendationsfor the Government, for regulators and forthose who commission or provide services forolder people.

Since the NSF was launched in 2001 therehave been many changes in national policy, in the NHS and local authorities, which havebuilt on the NSF, taken forward the olderpeople’s agenda, and/or influenced theenvironment in which public services operate.These are shown in appendix B.

The review took account of these changes,among others, and considered the collectiveimpact of the many developments that haveaimed to improve both services and the qualityof life for older people in recent years. Thereview was set in this wider context.

Although there have been many changes,these have moved in a broadly consistentdirection. Four themes have emerged fromrecent developments. These themes have arelevance that goes beyond services for olderpeople, as the growing emphasis onpersonalised services, choice, and the need toengage with users of services and citizens liesat the heart of the changes that are plannedfor all public services. The themes are:

Promoting wellbeing and active ageing

Older people want to remain active andinvolved in the community. Public servicesmake an important contribution, by providing arange of services and activities that promotethe mental and physical health of older people.

Choice, control and personalised services

Public services need to be tailored to theneeds and aspirations of older people asindividuals. This means that older people willhave much greater choice about the servicesthey use, and control over how, and by whom,these are delivered. Direct payments, orindividual budgets, are an importantmechanism for achieving greater flexibility.

Introduction continued



Citizenship and inclusion

Older people are much more than passiveusers of care services – they are citizens witha contribution to make. Engaging older peoplein making decisions about the issues thatmatter to them is therefore essential.

Leadership and supporting change

Good leadership and programmes of changeare needed in all organisations. The newdirectors of adult social care will play animportant role in building partnerships, whilelocal strategic partnerships and local areaagreements will be central in setting a shareddirection for all partner agencies.

The white paper, Our health, our care, our saybuilds on the above themes and sets out achallenging agenda for change, with acommitment to having more integratedservices which are built around the individual,more services delivered closer to home in thecommunity, and a focus on improving health.

As well as presenting a picture of the state ofservices for older people at the time of theinspections, this report also seeks to provideinformation and advice on how to improveservices for older people. The findings from theinspections are therefore supplemented withexamples from communities that were not partof the inspection, but may offer some insightsinto how some of the most common challengesmight be tackled. More examples are availableon the Healthcare Commission’s websitewww.healthcarecommission.org.uk.

This report also provides a platform for thevoices and views of older people collected byKing’s College London during our inspections.The findings of recent inspections of servicesfor older people carried out by CSCI and from the Audit Commission’s pilots of theolder people’s strand of comprehensiveperformance assessment, are also includedthroughout this report.

Findings on the views and experiences ofcarers are woven throughout the report, anapproach that mirrors the approach of theNSF, which views the issues of carers as ‘anintegral part of the way in which services areprovided for older people’.

The approach

This review had a broad scope. A number ofapproaches were necessary in order to reviewthe standards set out in the NSF, as well asthose issues highlighted by older people andother stakeholders as important, both sincethe publication of the NSF and for the future.The approach included:

• a scoping exercise to determine thebreadth and depth of the review

• 10 inspections

• extensive consultation and engagementwith older people

• analysis of national data

• visits to communities and services

Ten local communities were inspected to findout what services were like for older people.

In total, 40 NHS trusts and 10 local authoritieswere included in the programme ofinspection. A local community comprises ofhealth services, social care services, andother responsibilities of the local authoritysuch as leisure and community safety, thataim to improve wellbeing and quality of lifewithin a defined geographical area. Thisdefinition of a community is used throughoutthe report.

The communities were selected because aninspection of social care services for olderpeople was already planned or because theyprovided a range of urban/rural andnorth/south communities, as well as differenttypes of councils.

The inspections included the analysis of data,review of documents, interviews with key staffand focus groups, analysis of the case notes ofolder people and visits to observe a range ofservices. Each of the inspections focused inmore detail on one of three areas – stroke,falls or mental health. This area was thenused as a ‘lens’ through which services forolder people in the community could be seenand assessed.

King’s College London was commissioned forthis review to obtain the views of older peopleand their carers as well as those who workwith older people in local voluntary andcommunity organisations. A team of olderresearchers, a group known as Older peopleresearching social issues, obtained the viewsand experiences of older people in the 10inspected communities using a variety ofmethods, such as holding public meetings forolder people and distributing questionnaires.They interviewed 1,839 people face-to-faceand received more than 4,000 completedquestionnaires.

The teams carrying out the local inspectionsincluded inspectors from the HealthcareCommission, the CSCI, the Audit Commission,King’s College London researchers, olderpeople and advisers with professional expertisein one of the areas covered by the review.

The findings of the local inspections fed intoratings of performance for social services and,in some cases, contributed to thecomprehensive performance assessmentrating for the local authority. The findings didnot have a direct impact on the assessment ofthe performance of healthcare providers for2005/2006 but should help NHS organisationscarry out a more accurate self assessment,which is part of the Healthcare Commission’snew annual process to assess performance.

A report has been published for each localinspection and these can be found on theHealthcare Commission’s websitewww.healthcarecommission.org.uk. Copies of the reports including the social care aspectsare available on CSCI’s websitewww.csci.org.uk.



The 10 local communities inspected

Buckinghamshire LeicesterBrent DorsetLiverpool PortsmouthRedcar and Cleveland WiltshireGreenwich Medway


Involving others in the review

Involving and listening to key stakeholders hasbeen an important feature of this review andhas involved a large number of organisationsand groups.

An important part of this engagement processhas been a strong emphasis on involving olderpeople in the development of the work at allstages. Older people were involved in shapingthe scope of the review through a series ofmeetings and workshops, and havefundamentally influenced the approach todeveloping the methodology and carrying outthe inspections.

Professional bodies, groups and organisationsat local, regional and national levels, as wellas staff who have direct responsibility forimplementing and delivering the NSF, havealso been involved extensively in the shapingof the review and the local inspection process.Five stakeholder events were held around the country, which was attended by a total of500 people.

A full list of all the organisations that wereconsulted is listed in appendix A.

Standards and themes

The NSF includes standards on specificservice settings, generic issues, andconditions that are particularly significant forolder people.

Most of the other NSFs published by theGovernment also relate to conditions thataffect older people, so they are also relevant.These cover areas such as mental health(1999), diabetes (1999), coronary heart disease(2000), and long term conditions (2005).

The National Service Framework for OlderPeople recognises that conditions such asstroke and dementia are not limited to olderpeople and the standards and service modelsin the NSF should apply to those who needthem, regardless of their age. There are eightstandards, supplemented by guidance andmilestones on medicines and older people.

The eight standards set out in the National Service Framework for Older People

Standard 1: rooting out age discrimination Standard 2: person centred care Standard 3: intermediate care Standard 4: general hospital care Standard 5: strokeStandard 6: falls Standard 7: mental health in older people Standard 8: the promotion of health and active life in older age



During the planning of the review, a number ofthemes were identified that run through the NSFand link all the standards together. The themeswere chosen because they are key issues thatunderpin the successful delivery of all the

standards. By using these themes theinspections were able to build up a broad pictureof services for older people in a community, andhow these fit together, as well as focusing onsome of the detail of delivering services.

Themes identified for the review

Tackling ageism and promoting equality

• are older people at a disadvantagebecause of their age?

• are some groups of older people moreaffected by discrimination than others?

Involving older people

• to what extent do older people have avoice in the decisions and developmentsthat affect them?

Designing and delivering services aroundolder people

• are the whole range of needs andaspirations of older people taken into account?

• is the single assessment processcontributing towards this?

Stroke, falls and mental health services

The review paid particular attention tolooking at services related to stroke, fallsand mental health. These areas were usedas a ‘lens’ through which to assess servicesagainst all the standards and themesduring the inspections.

Living well in later life

• are partner agencies working togetherto ensure that older people are able tolive full, active, healthy lives?

• what role are care services playing inhelping older people to liveindependently?

Leading organisations through change

• is partnership working helping toimprove services for older people?

• are organisational factors such asleadership, finance and workforcestrong enough to support change?


Tackling ageism and promoting equality

“At the civic hall we are worried that they will cut dancing for older people,concentrating on the young. We don’t like tocomplain but we know if someone else needs the room it gets cancelled. We are at the bottomof the list.”


This section is about how the 10 localcommunities have tackled ageism anddiscrimination, the gaps in service that have aparticular impact on older people, the balanceof services provided to urban and ruralcommunities and how well organisations weremeeting the needs of older people in diversepopulations.

Discrimination can have profound and far-reaching consequences on the lives of olderpeople. They may experience discriminationand disadvantage for a variety of reasonsapart from their age. It may be on grounds offaith or sexual orientation, because they areblack or disabled, or combinations of these.Social deprivation, too, has a significantinfluence on the experiences of peoplethroughout their lives, as well as on theirwellbeing in later life.

The forthcoming Commission for Equality andHuman Rights will have broad powers topromote equality and respect for diversity andhuman rights, and will have a duty to promoteequality as an end in itself. The RaceRelations (Amendment) Act 2000 establisheda general duty for specified public authorities,requiring them to work towards theelimination of unlawful discrimination and topromote equality of opportunity and goodrelations in carrying out their functions. The Disability Discrimination Act 2005 alsoestablished a public sector duty to promoteequality of opportunity for disabled people,(coming into effect in 2006) and the EqualityBill proposes a similar duty for publicauthorities relating to gender.

Key messages

Overall there has been a reduction inexplicit age discrimination in planningservices, policies and provision of servicesexcept for older people with mental health needs.

A number of older people reported poortreatment that indicated ageist attitudes or practice.

Some gaps in service affect older peopledisproportionately, particularlyif they have low incomes. These includetransport, podiatry and dental care.

The impact of champions for older peoplein challenging age discrimination is difficultto assess.

Older people who live in rural areas areless likely to have access to a good rangeof services than those living in moreurban areas. Community based careservices are a particular area of concernbecause of difficulties in covering widegeographical areas.

Services for older people are at an earlystage in addressing diversity issues,although the inspections highlighted someinnovative developments.


Access to services

Health and social care organisations havestarted to tackle age discrimination byauditing policies on access to services andreviewing criteria for eligibility. Older peoplehave had quicker access to some operationsand procedures since the NSF was published.

According to the Audit Commission’s reviewon national progress against the NHS plan5,76% of organisations surveyed had reviewedtheir criteria for eligibility to services, asrequired by the NSF. Of these, 38% hadimplemented necessary changes. The localcommunities inspected for this report hadalso taken action to identify and changepolicies that were explicitly ageist.

Assessing whether services are provided fairlybetween age groups is not straightforward,not least because many organisations cannotprovide detailed data on who uses theirservices. In addition, for many healthprocedures used chiefly by older people, thecomparison with younger age groups isunlikely to be helpful.

Access to cardiac procedures and hip andknee replacements by people over 65 haveimproved since the NSF was published.Information from the Department of Health’shospital episode statistics showed thatbetween 1999 and 2004 the number of hipreplacements carried out on people agedbetween 65 and 74 years increased by 39%and for people 75 years and older increasedby 22%. The number of knee replacementscarried out on people aged between 65 and 74increased by 58% and for people 75 years and

older it increased by 63%. There has been ageneral increase in hip and knee replacementsfor the whole population as surgical procedureshave increased to achieve the waiting timetargets for admission to hospital. However,despite this there were was a higher increasein access to hip and knee replacements forolder people. Social deprivation negativelyaffects the access to treatment for olderpeople. Nationally, there were feweradmissions of older people to hospital for bothhip and knee replacements in poorer areas.

Likewise, access to procedures relating toheart failure has increased for older people.Elective (voluntary) admissions for peopleaged between 65 and 74 years have had a 54%increase, while there has been an increase of129% for people who are 75 years and older.This indicates that, despite the generalincrease in the admissions of people of allages to hospital for elective procedures,access by older people to these procedures,had also increased. This may be due to arevision of policies on age discrimination butthis explanation is not conclusive, as thedemand by older people for these procedureshas risen.

Ageist attitudes

Progress has been made in tackling agediscrimination through equal access to servicesdepending on need. However, some examplesof ageist practice or behaviour were still foundin some services. In some acute hospitals, forexample, older people were receiving poortreatment because of their age.

Tackling ageism and promoting equality continued


Although age discrimination audits had beencarried out, this is only the first step inensuring that older people can be confidentthat they will not be discriminated againstbecause of their age. There was little evidenceof staff receiving training to help themchallenge ageist attitudes.

Many of the older people involved in thisreview had experienced ageist treatment, withsome highlighting a negative change inattitude and availability of services followingthe transition from one service to anotherwhen they reached the age of 65.

Organisations had their own policies topromote equality and ensure fair access to services, but these were rarely broughttogether within a coordinated programme.

Older people highlighted a number of caseswhere they had received an inferior service, or had been prevented from using a service,purely on the grounds of their age. Forexample, one leisure centre had barred olderpeople from using its equipment because anolder man had suffered a heart attack duringan exercise session. In a day centre, whichcatered for people with physical disabilitiesand older people, there was preferentialfunding for the group with physical disabilities,resulting in the older people having feweractivities and a less varied programme.

Mental health services

While there has been improvement in accessto services for older people, there is furtherwork to do to provide equal access to the full

range of mental health services that areavailable for adults of working age.

There are poorer and less integrated servicesfor older people with mental health needscompared to those people with mental healthneeds aged under 65. The out-of-hoursservices for psychiatric advice and crisismanagement for older people were much lessdeveloped, and older people who had madethe transition between these services whenthey reached age 65 said there werenoticeable differences such as poorer quality,fewer services and less support.

Although there were agreed protocols fortreating dementia and depression and formanaging people with dementia in acutehospitals in all the communities we inspected,their impact and the awareness of them bystaff were limited. Older people with dementiafrequently had unacceptably long waits for theprovision of specialist long term care and thecare they received when in hospital revealed alack of understanding of their needs. We alsofound that older people with cognitiveimpairment did not have access tointermediate care and therefore were unableto benefit from rehabilitation to regainphysical ability.

“Older people were promisednational healthcare from thecradle to the grave, and that’snot what they’re getting withdental care and chiropody.”


Dentistry

Many older people experienced difficulties infinding an NHS dentist, particularly in ruralareas, meaning that opportunities forpreventive dental healthcare and treatmentwere not available. Set against national data,which shows that older people from deprivedareas tend to have higher rates of total toothloss, there is a clear disadvantage to thosewho cannot afford to pay for treatment. FromApril 2006, however, primary care trusts(PCTs) will be given devolved budgets tocommission NHS dental services, in anattempt to redress the chronic shortages insome areas.

Podiatry

Many older people referred to changes inpodiatry services and how they now had to ‘goprivate’ or suffer very long waits for NHStreatment. Podiatry services appeared underresourced in all the areas inspected. Manyolder people spoke highly of the ‘one stopshop’ approach, whereby podiatry and otherservices were provided in day centres.

Services for the clipping of toe nails, whichran alongside more comprehensive podiatryservices, were very important to by olderpeople. Although these are not costly services,they are often provided by the independentsector, including voluntary organisations. We found that there were frequently delays inproviding this service because of discussionson issues such as liability and training.

Transport

There was a lack of reliable and accessibletransport in all the areas we visited. Thiscontinues to put older people at adisadvantage, preventing them from gettingaccess to goods, services and social contacts.Compared with the national average, olderpeople living in households which do not havea car, are more likely to have higher rates ofmortality, and to end their days in residentialcare (Breeze et al 1999)6. National statisticsshow that a lack of access to transport isexperienced disproportionately by olderpeople, and especially by older women withdisabilities (Davis 1998)7.

Champions for older people

Champions for older people have aresponsibility to root out age discriminationand to promote the interests of older peopleand services within their own organisationsand beyond. Many champions were clearlyvery committed, but they operate largely inisolation of one another, with little interaction,no real training or clear definition of roles and(among the professional champions) no timein their working week formally dedicated tothe role. In one group meeting with olderpeople no one could name or rememberseeing a champion for older people.

The Department of Health established the network of champions for older people and provided central support withregular information bulletins and training on leadership.



However, this programme was only fundedfrom 2001 to 2004. There is still a loosenetwork of champions for older people butwithout central and local support and fundingit is uncertain how long the network willremain and whether it can continue to have aneffect in improving services for older people.

Equality and diversity

The local communities that we inspected thathad significant black and minority ethnicpopulations, provided some services tailoredto their needs. For example, in Leicester,specialist home care was provided and agroup of ‘peer educators’ worked with oldersouth Asian people to help raise awareness ofrisk factors for coronary heart disease anddiabetes. However, in communities with lowernumbers of black and minority ethnic olderpeople, awareness was variable andappropriate services were underdeveloped.This is consistent with findings from the recentCSCI inspections of services for older people,which found that, of 18 councils, only threewere performing well in providing services forblack and minority ethnic older people.

Few of the local communities inspected hadjointly developed strategies for equality anddiversity, but in several areas this was beingaddressed through strategies for jointcommissioning and working groups. Therewere some examples of good services. Forexample, the needs of older travellers werereceiving particular attention in Wiltshire andLeeds, the latter having gained knowledge andunderstanding from the experience of

Romanian partners, in a European programmepromoting development of services with andfor older people in minority ethnic groups. Inanother area, the needs of gay and lesbianolder people were being met through a ‘gayand grey’ support group. A group fortransgender older people that meets in aservice setting for all age groups was cited asbeing very supportive for its members, someof whom travelled long distances to accessthis specialist service. Such examples werecomparatively rare, however, and there weresome examples of distressing reports ofsame-sex couples experiencing insensitivetreatment and behaviour.

Geographical issues – rural versusurban life

There are clear differences in the range ofservices available in urban and rural areas. With home care, for example, attracting andretaining the staff to provide care for people inremote villages was a challenge for providers of services. Older people often experiencedservices that were unreliable and fragmented.

In addition, some providers did not pay for the time staff spent travelling betweenhouseholds. In rural areas where distancesbetween users of services are great, this is asignificant problem.

“Older people are concernedabout access to health fromrural areas.’’


This is an area where many local authorities arefinding difficulties. This is in part due toproblems of recruitment but is also linked tothe need to develop a range of approaches tocommissioning, many of which need to becomemore tailored to particular local conditions. TheCare Services Improvement Partnership iscarrying out a review of intensive home careand this will include looking at delivery of homecare in rural areas. Local authorities areadopting a wide range of approaches to thisproblem, from focusing on large block contractsin rural areas to developing the capacity ofsmaller, local organisations. Other approachesin use or being considered include:

• recognising the additional costs ofproviding a rural service, including travel,through service level agreements

• moving away from opportunistic, spotpurchasing towards a position whereproviders can predict demand moreaccurately and retain staff

• paying local people who are willing toprovide support to a neighbour by usingdirect payments

• linking workforce planning, includingrecruitment, induction and training, withthe independent sector

• changing the role of in house services sothey become more specialist rather thandirectly competing with the independentsector

• working with black and minority ethnicgroups to encourage them to becomeproviders of services

• the use of a specific resource to provide acare ‘hub’ with less intensive servicesbeing delivered into the surrounding area

Older people also said that travelling longdistances to health facilities such ascommunity hospitals resulted in difficultieswith visiting and attending appointments.There were concerns about out-of-hoursservices provided by some GPs as some olderpeople had difficulties in accessing GPs atnight and at weekends. One older person,whose friend telephoned the out-of-hoursnumber on a Saturday, said: “It washorrendous – they didn’t turn up until the nextday, they had no notes and couldn’t doanything for him”.

Solutions that are innovative and creative arerequired to meet the challenge of deliveringservices in rural areas.

The following example highlights Leeds CityCouncil’s work to build capacity with blackand minority ethnic groups in order toencourage the development of services thatare sensitive to the needs and aspirations ofblack and minority ethnic older people.



Working with black and minority ethnic older people in Leeds

“It's a great project. We see things here from one side of the coin. But venturing into othercities in other countries, we see the other side. Then we can sum up and compare, and weknow that Leeds are trying their best.”

A black and minority ethnic older person from Leeds, talking about the SEEM II European project

Background

Leeds City Council social services raceequality forum has been working with olderpeople from local black and minority ethnicgroups to develop services with and forthem. Organisations involved include LeedsBlack Older People’s Forum, the SikhWelfare Trust and the Chinese community.

Extensive dialogue between faith groupsand voluntary organisations led todevelopment of ‘neighbourhood networks’for black and minority ethnic older people, which have helped to improvecommunication, understanding and servicedevelopment. This work is supported by theServices for Elders from Ethnic Minorities(SEEM) project – a European programme todevelop and promote solutions to improvehealth and social care for people from thesegroups. The initiatives in Leeds address anumber of areas, including improvinginformation, developing neighbourhoodnetwork services and lunch clubs, homecare, supporting carers, day services,including a ‘Dementia Café’ for people withdementia to meet, residential and nursingcare, housing, consultation and involvement.

Successful outcomes include:

• Supporting older people to becomeservice providers, information days incouncil offices, faith organisations,temples, gurudwaras and other venues.

• Promoting the benefits and employmentopportunities for older people with thecouncil.

• Mobilising resources by the council inthe Sikh community to develop daycentres for Sikh older people.

• Working with the Chinese community todevelop services.

• Establishing successful networks withgypsy and traveller communities.

Since it opened the number of participantshas increased steadily, demonstrating theneed and importance of such services forblack and minority ethnic older people.

Learning points

• It is important to engage with olderpeople, faith and community leaders inblack and minority ethnic groups.

• Enabling the community to become self-reliant by mobilising the services withinthat community is of greater, lastingvalue than funding specific services forspecific communities. Such an approachhelps to ensure sustainability.

• Undertaking careful analysis of acommunity’s needs, before embarkingon service development, helps ensurean understanding, an acceptance and awillingness to participate.

There are plans to develop extra care,sheltered housing and domiciliary care services.


Involving older people

“We’ve always said, respect our skills, and respect our experiences. They need to be paid for, so pay us a fee, pay for our transport because you want us there – not because you think you need usthere, but because you want us there.”


A person centred approach – where the needsof the individual guides the services – has anumber of different aspects. Firstly, olderpeople need to have a voice in building a visionfor the future, in planning and developingservices, and in influencing the most importantaspects of community life. This is the subject ofthis section. Secondly, when they do need extrasupport, their needs and aspirations should beat the centre of any decisions made, asdiscussed in the next section.

Earlier work by the Audit Commission (2002)8

found that improving services across thewhole system – that is, all the organisationsthat are involved in services – for older people

relied on all partner agencies having a sharedsense of direction, rooted in the views andaspirations of local older people. A sharedvision for the future that reflects the prioritiesof older people and their aspirations createsmomentum for change.

However, good engagement with older peopleis important not just because services arelikely to be better if people who use them andthe people who pay for them are involved intheir planning. Evidence also suggests thatolder people who take on active roles aremore likely to report that they have betterhealth and wellbeing than those who do not(O'Reilly and Caro 1994; Rozario et al. 2004)9.

Key messages

Older people do not feel that they had avoice in planning and shaping services –more than 95% of older people surveyed hadnot been asked for their views of the NHS orcouncil services in the last year.

Around 80% of older people asked do not think that they influenced the planningof services.

There is very little evidence that inspectedcommunities are building a shared vision based on the views and priorities ofolder people.

Many older people are sceptical about thevalue and impact of consultation andengagement exercises.

All inspected communities are involvingolder people in various ways, but this is notalways systematic or carried out routinely.

Local authorities have mechanisms that arebetter developed than those in the NHS forengaging with older people. Some localauthorities deal with the wider concerns ofolder people as citizens rather thanexclusively as users of care services.

Most inspected communities are finding it achallenge to involve older people who areseldom reached, such as older people inblack and minority ethnic groups, older peoplewho are housebound and older people withmental health needs.


Older people who contributed to the localinspections had very different individualexperiences of being involved in decision-making. Of the people who responded to thesurvey carried out by King’s College Londonas part of the inspection process, more than95% said they had not been asked their viewsof NHS or council services in the last year. Inaddition, around 80% felt that older peoplehad no influence in planning health and socialcare services or in monitoring their quality.

The views and aspirations of older people hadnot made a significant impact on the prioritiesand direction of all the partner organisationsin the communities that were inspected. Fewcommunities had a shared local vision forlocal older people that set out the direction for the future and the contribution of partnerorganisations in improving the lives of olderpeople. When older people are involved inshaping vision and strategy, the scope of thistends to go beyond care services to includeissues such as learning, leisure, transport andcommunity safety, as these are the factorsthat research consistently shows make mostdifference to the lives of older people.

In some local authorities there were earlysigns that the views of older people werestarting to make a difference, for example byinfluencing the approach of local authority totransport or community safety. However, thiswas rarely as part of an explicit vision thatwas shared with the NHS and other partners.

All the communities that were inspected wereusing a range of methods to consult andcommunicate with older people – at times

with them directly as local citizens, morefrequently as users of services or patients,and sometimes with voluntary and communitygroups. There was a wide range of structuresand mechanisms in place, including groupsthat related primarily to the local authority, aswell as various patient and public involvementprocesses in the NHS. This point is echoed bythe early findings from the AuditCommission’s pilot corporate assessmentinspections of local authorities, which foundthat a varied range of mechanisms forinvolving older people were in place, some ofwhich were better established, and led moreby older people than others.

In general, however, the diversity of groupsand processes meant that the involvement of older people was not systematic orcoordinated well and the impact of olderpeople’s involvement in making decisions wasnot always evident. In addition, the purpose ofsuch activity was not explicit, and partnerorganisations were unclear whether they were:

• engaging with older people as citizens andtax payers

• involving older people in decision-making

• consulting on the detail of how serviceswere delivered

In very few of the inspected communities wereall partner agencies working together tomaintain a debate with older people about arange of issues. Older people, complained ofduplication and ‘consultation fatigue’. A lackof clarity about purpose and expectations ledto confusion, and there was a widely held

perception that the views of older people wereunlikely to be acted on.

Older people were frustrated at the ways inwhich consultation exercises have becomemore frequent, without necessarily becomingmore meaningful. Not everyone wasconvinced that consultation was ‘real’ andsome older people expressed the view thatpartner agencies were involving them onlybecause they were obliged to do so.

Older people were also sceptical of the valueof consultation exercises carried out byvoluntary organisations.

NHS organisations were, in general, lessengaged with networks of local older peopleand less developed in their understanding andpractice than local authorities, most of whichhave a track record of working with localcommunities and partners.

However, in the NHS there were good examplesof involving older people in the redesign andimprovement of services they had used. Theseincluded services for people with dementia andpeople who had a stroke. There were exampleswhere older people could see the direct impact

of their contribution on the way that serviceswere delivered.

There were some examples of partnerorganisations working to engage with theirincreasingly diverse older populations, but notin a very systematic way. Services forinterpretation and translation were scatteredand not widely known beyond specific groupsor organisations. Many communities werestruggling to engage with older people withmental health needs. Although older peoplewith cognitive impairment might find itdifficult to talk about abstract ideas or events,they were able to comment on services usedon a day-to-day basis.

In some areas, communication with thevoluntary and community sector acted as one route for local councils to consult andreceive feedback, to think about localimplementation of new systems and policies,and to gain support for local initiatives.However, engagement with voluntaryorganisations is not the same as involvingolder people – it is an additional route, not asubstitute for direct communication. It isencouraging that all the inspectedcommunities recognised this and wereemploying a range of methods to involveolder people in direct debate about theshape of services.

The following example illustrates how onecommunity is attempting to build asystematic, democratic approach to involvingolder people, as citizens, in debate aboutpublic services.

Involving older people continued


“We don’t get asked what wethink, we would welcomemore opportunity to say whatwe want from local health andsocial services.”


An example of involvement – Brighton and Hove Older People’s Council

“The older people’s council is a striking example of demonstrating the commitment to involvement”.

Background

Brighton and Hove Older People’s Council,is one of the first directly elected groups ofits kind in the country. It is a real innovationand offers older people the chance to havea voice in the decisions that make animpact on their lives. The council’s ninemembers, each representing a zone of thecity, are elected by older people in Brightonand Hove to represent their interests.

The older people council’s work covers abroad range of issues that are important toolder people, from promoting lifelonglearning to influencing planning decisionstransport and community safety strategiesand improving care services. Each memberhas a special area of interest and maintainsclose links with relevant decision-makers,such as local authority committees, NHStrust boards and city wide partnershipgroups. The nine council members workclosely with a larger group of older people inBrighton and Hove, the Brighton and HoveCoalition of Older People – the pensioners’forum. The pensioners’ forum is a diverse,fluid group with around 2,000 members, whocampaign and provide information on issuesof importance to older people, challenge agediscrimination and stereotypes and createopportunities for older people to becomeinvolved in new activities. These includeSilver Sounds, a Samba band, which hassuccessfully raised the profile of olderpeople in the city and beyond. The diversityof the pensioners’ forum provides anexcellent reference group and soundingboard for the older people’s council.

There is growing evidence that the olderpeople’s council is making a difference. Theneeds and aspirations of older people arenow considered routinely when decisions aremade on planning and regeneration, andmembers of the council play an importantrole in promoting the value of the contributionof older people to the community.

Learning points

Leadership and commitment from electedmembers of all parties, working alongsideolder people, has been crucial in buildingand sustaining momentum.

The agenda of the older people’s council isset by older people, with a primary focus onissues of most importance to them, not onservice priorities.

Offering opportunities to become involvedand have fun helps build networks of olderpeople, who can then be called upon to helpin public engagement exercises.

The success of the older people’s councilrests on the mandate it was given byBrighton and Hove’s older voters and alsoon the credibility of individual members –this can only be built over time, as membersare seen to be making a difference.

The older people’s council’s next challengeis to work with the local authority, NHS andother partners such as Better Governmentfor Older People to develop a local strategyfor an ageing population.


Designing and delivering servicesaround older people

“I was very happy with the…care. It’s the effect on my life because I’ve got people who care; it gives my feelingsabout human nature a leap – I realise I’m not just me, I’m a person.”


This section looks at the extent to whichservices are genuinely tailored to the needs andaspirations of individual older people, andidentifies factors that contribute to this. Itexplores whether older people are treated withrespect and sensitivity when they come intocontact with services. It also assesses progressin implementing the single assessmentprocess, with tackling delayed transfers of care,and the impact of these on older people. Thesection touches on how well older people thatare vulnerable are protected, as well as lookingat the use of direct payments, individualbudgets, and systems for complaints.

Older people said at the events we held forthem in each of the communities that theyvalued the services they received most of thetime and expressed praise and gratitudetowards the staff who delivered them.However, the inspections also revealed areasin which there was more to be done andwhere older people perceived that they hadnot been dealt with appropriately by care staff.

Hospital care

Conditions in hospitals sometimes had asignificant impact on the experiences of older

Key messages

Most older people valued the services theyreceived and feel that their dignity isprotected when using services.

There were a number of instances whereolder people were not treated withsensitivity and respect. Single sex wardsand bays in hospitals were being used toaccommodate men and women together,and there was poor understanding amongacute hospital staff of the needs of olderpeople with dementia.

While all communities were striving toimplement the single assessment process, ithad not been fully implemented in any of thecommunities, resulting in the continuation oflengthy, disjointed assessments that failedto address the whole range of needs andaspirations of older people.

Delays in transfers of care from hospitalhad fallen in all of the inspectedcommunities.

The discharge of older patients fromhospital was not always managed well andstaff do not always respect the needs ofolder people and their wishes.

The procedures for protecting vulnerableadults were established in most communitiesbut the monitoring, reporting and analysis ofincidents of abuse and the outcome ofinvestigations could be strengthened.

Many older people said they were reluctantto complain about services and not all(ranging from 27% in one community to59% in another) are confident that theircomplaint would be were listened to.

Designing and delivering services around older people continued


people of being an inpatient. For example,there were many comments from older peopleabout dirty wards, the strong smell of urinefrom unemptied bottles, and people waiting ontrolleys. According to surveys of NHS patients,just more than 50% of respondents thoughthospitals were clean, but this number droppedto around 40% when they were askedspecifically about toilets.

The inspections carried out in the localcommunities confirmed that some older peoplestill had unacceptably poor experiences of inhospital, and in particular:

• there were some wards and bays which,although designated as single sex, wereregularly used for people of both sexeswhen the hospital was busy, and in somecases there were no plans to address this

• there were some instances of older peoplebeing moved from ward to ward, sometimesat night. These moves were not always forclinical reasons

Older people who are most vulnerable are mostsusceptible to poor treatment in hospital. Ashighlighted previously, there were particulardifficulties for older people with mental healthneeds when cared for in general hospitals. Theinspections found instances where people werenot well monitored to ensure that they liked –or had even eaten – the food prepared forthem, and meals were taken away untouched.In Buckinghamshire there is a trainingprogramme for nursing staff aimed atimproving the care in hospital of older peoplewith mental health needs.

The singleassessment process

None of the communities that were inspectedhad introduced one model of singleassessment across all partner organisations inthe area. This is in line with CSCI’s findingsfrom inspections of services for older people in

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Work is still at an early stage

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with NHS partners but not yet implemented

A single processhas been agreed

and implementation has begun

A single process is fully operational across all

health and social services in the council’s area

Source: Padi 2156 Progress on NSF milestones: stage reached in implementing a single assessment process

Figure 1 – Progress of local authorities and partners in implementing one model of thesingle assessment process


2004/2005 that found only 6% of localauthorities nationally had a single assessmentprocess for health and social care (see figure 1).

Two of the inspected communities hadintroduced single assessment across the areausing more than one model, and seven were atvarying stages of piloting its implementation.The remaining community that we inspectedplans to implement single assessment once ITsystems are available in April 2006.

Older people emphasised the importance ofreceiving services that are well coordinated, orjoined up. To achieve this, there should be onecoordinated assessment of the needs andaspirations of older people. Multipleassessments mean that older people are likelyto be asked the same questions repeatedly,while other important areas remain ignored. Ashared approach reduces the likelihood ofconfusion and means that critical issues aremore likely to be jointly understood and actedon. In addition, older people wanted theirunique combination of experiences, aspirationsand hopes for the future to be recognised,rather than have uniform solutions imposed onthem that focused only on problems.

There was little evidence of an approach toassessment that genuinely placed the olderperson at the centre, and that focused on theissues that the older person saw as mostimportant. CSCI reached a similar conclusionwhen it inspected services for older people in18 councils between April 2004 and March2005. It found that the views and aspirations ofolder people were not clearly recorded. But inthe one local authority where staff had beentrained to use the words of the older person inrecording the assessment, this had led to a

much more personalised approach, as well asmore creative packages of support.

Factors which were affecting implementationof the single assessment process included:

• project management of the introduction of single assessments did not pay enoughattention to delivering the requirements of the national service framework (NSF)on time

• the lack of a shared electronic system forkeeping records was seen as a majorbarrier for some although others wereusing paper-based systems as an interimsolution

• testing of single assessments was limited,as most inspected communities werepiloting but not yet using this method forall older people in their area

• interagency evaluation of the process wasoften incomplete and the process for doingso was not always agreed

• the introduction of new approaches torelevant groups of staff was often at anearly stage

• multidisciplinary training of staff hadstarted in most areas, although somereported difficulties in getting all partnersto attend in sufficient numbers

• staff in hospitals and in GP surgeries wereoften the least engaged in the process

• there were difficulties and disagreementsabout what information could be sharedbetween partners

The single assessment process is the foundationfor building services around individuals, a key



objective of the white paper Our health, our care,our say. The limited progress on this washindering the development of thinking andworking with an integrated approach. Theunderstanding by partner organisations of thechange in culture which is needed to makesingle assessments work, was variable. Withouta person centred approach and joined upworking, there are poor results for older people,care planning is underdeveloped, the needs andaspirations of older people are ignored anddelays are caused by the fragmented nature ofthe assessment process.

In some communities, the absence of a jointsystem for information had been used tojustify a lack of progress, but in others thishad not prevented some progress being made.In these communities at least some olderpeople were benefiting from a joint process,even if it was paper rather than electronicallybased. For those older people who hadexperienced a single assessment there wereearly indications of the benefits that could begained. In particular some older people saidthey liked being able to keep their sharedrecord with them at home. The inspections of local communitiesindicated that a single assessment process forolder people was also thought to be bringingother benefits, in particular:

• more consistent and regular reviews ofcare and support

• greater coordination of systems tosafeguard older people

• better systems to review prescribedmedication

But these benefits are still just aspirations inmany areas because of the substantial delaysin realising the target of one coordinatedassessment and review process. Four yearsafter the publication of the NSF, the role ofstrong leadership in ‘selling’ and promotingthe single assessment process at board leveland in guiding changes in culture andoperational delivery, is more important thanever. New approaches to delivering publicservices emphasise the importance oftailoring services to meet the needs andaspirations of individuals. Our health, our care,our say, Independence, wellbeing and choice,and Opportunity age, all set out clearobjectives to ensure that older people havemore control and choice over the servicesthey receive. Person centred planning isdescribed as one way to achieve this, buildingon the experience of using the singleassessment process. It is therefore importantto implement single assessment, and toincrease understanding of the change inapproach that this represents. Without this,older people are unlikely to receive aresponse that genuinely reflects their uniquecircumstances and preferences.

Information andcommunications

Older people valued being given the rightinformation by staff in the right way and at theright time. However, the extent to whichprofessionals took care to ensure that peopleunderstood why they had been referred forcertain investigations or prescribed certainmedication varied.


The inspections found incidents wherecommunication had been poor and theinformation provided was inadequate. Forexample, when some older people were givena diagnosis, insufficient time was taken todeal with this sensitively, and little supportwas offered in adjusting to their changedhealth status.

Many older people felt that professionalsfailed to take account of the in depthknowledge that they and their carers couldprovide, and underestimated their capabilityand understanding. For example, older peoplewith physical disabilities reported that healthand social care staff often assumed that thiswould mean that they were incapable ofexpressing their views themselves.

They also found it difficult to find out aboutservices, particularly primary care and adviceon benefits. There was a mixed response toweb-based information services, althougholder people appreciated websites that targetpeople over 50, with links to other relevantinformation. Most local authorities providedfree newspapers, which were valued, as wasinformation provided by voluntaryorganisations such as the Stroke Associationand Age Concern. Several people commented

that they would expect GP surgeries orhealth services to be an appropriate place tofind information, but this expectation wasrarely met.

A recurrent theme was the need for timelyinformation that was easily available and writtenin non-technical language. The difficulties fororganisations of providing a highly complexrange of information covering general adviceand specific detail were also acknowledged.Some communities that were not part of theinspections have tackled this by producingsignposting leaflets for older people. Thesebring together sources of further informationand help on a wide range of issues, from sportsand clubs to benefits advice and care services.

Some of the communities inspected providedgood information to promote wellbeing.Partner organisations in Redcar and Cleveland,for example, had published a booklet calledChoose life, choose health and another on theprevention of falls. In Portsmouth theinnovative Prevention Network had made a realdifference to the sharing of information andconcerns between statutory organisations andlocal community and voluntary groups.

There are additional issues confronting peoplefrom minority ethnic groups, in particular ifthe older person does not speak English.Access to interpreting services is inconsistentand staff who speak minority ethnic languagesare not always available to deliver ongoingcare. Not all partner organisations recognisethat it is inappropriate for older people to haveto rely on relatives to communicate intimatepersonal and confidential matters to doctors,nurses or social workers. This is a particularproblem in the NHS. Asking relatives to act as

“It took three weeks, day afterday, to get help. No crossover.You have to find your waythrough the woodwork.You’re feeling isolated, atyour lowest ebb.”



interpreters for older people is not acceptableand should be discouraged. Even where thereare clear policies about interpreting andtranslating, staff knowledge of them oradherence to them appears variable.

Hospital discharges andreadmissions

The inspections of the local communitiesconfirmed the national trend of falling numbersof older people delayed in hospital. TheDepartment of Health’s statistics show thatthere has been a 67% reduction in delayedtransfers of care from 5,396 in 2001 to just1,804 in 200510.

However, some communities have struggledto provide the range of safe and suitableservices outside hospital, which will help toavoid unnecessary stays in hospital andpromote speedy discharge. Since 2004, as away of strengthening partnership working totackle this issue, local authorities have beenrequired to reimburse hospitals where it wasclear that the delay in discharge of a patientwas their responsibility11.

Although delays had fallen in all inspectedcommunities, in some cases rapid dischargewas only achieved at the expense of properplanning with the older person concerned.The inspections found that:

• while the majority of older people reportedthat they had had a timely and wellorganised hospital discharge (between81% and 63% across the communitiesinvolved in the survey), a significantminority did not

• discharges and ward transfers of olderpeople and their carers were sometimesdone at inappropriate times

A CSCI special study report in 200512

followed up a group of patients who werestudied in a previous report Leaving hospital– the price of delays (2004)13. One year on,they found that:

• in all places visited further steps had beentaken to improve the speed andcoordination of discharge, anddevelopments in community services wereevident everywhere

• older people were largely satisfied andgrateful for services received, althoughfamily carers were more likely to voicegrievances

• continuity of carers was a top priority forolder people

• intermediate and rehabilitative serviceswere universally appreciated by the usersof services, but varied widely across thecountry in terms of their accessibility.A focus on rehabilitation results insustained improvement and themaintenance of independence

• shortfalls in community health servicesundermine the potential to deliver goodpost hospital care and prevent admissionin the first place

• the reimbursement scheme improvedpartnerships between health and socialservices, and these constructivepartnerships have been sustained

• there should be a greater focus onproviding practical and flexible support for


carers. The pressure on some carers wasevident, particularly those who werecaring for older people with both physicaland mental health needs

The Department of Health’s change agentteam set out the components of a gooddischarge planning service14. These are shownin the table below.

Rates of readmission have increased over thepast three years, particularly for people aged75 and over. While this is not conclusiveevidence of inequality, it is of concern thatreadmissions are increasing and that theyappear to be increasing disproportionatelyamong older age groups. Sometimes an olderperson may be readmitted to hospital but fora different reason than their originaladmission, and this is unavoidable. To explorethis further, two disease areas wereconsidered to look at readmissions – diabetes

and chronic obstructive pulmonary disease(often referred to as COPD, a condition whichaffects the ability to breathe easily).

Figure 3 shows the ratio of readmission tohospital within 30 days of discharge forpeople with diabetes as a percentage of thepopulation between 1998/1999 – 2000/2001and 2001/2002 and 2003/2004. There hasbeen an increase in readmissions for allpeople between the ages of 50 and 75 andover. The readmission rates for people agedbetween 50 and 64 increased by 5%. Forpeople aged 65 to 74 it increased by 6%. Theincrease in readmission rates for people withdiabetes who are 75 years and older ishighest at 10%.

Figure 3 shows emergency readmission ratesfor people with chronic obstructive airwaysdisease within 30 days from hospital as aproportion of the population.

A good discharge should include:

• a mix of professionals (social workers, nurses, therapists) working and located togetherin the same team

• a single line manager or coordinator

• an agreed multi-agency discharge policy including when and how to assess foreligibility for continuing healthcare funded by the NHS

• early referral so that planning for discharge starts as soon as possible

• early identification of an estimated discharge date that is communicated to all keypeople, including patients and carers

• coordinators based in wards who can oversee the discharge process, both for the 80% ofpatients whose discharge is straightforward, and the 20% who have more complex needs

• active involvement of patients and carers in the planning and decision-making process

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Source: Median indirectly standardised 30 day emergency rates of readmission for diabetes (data pooled for 1998/1999-2000/2001 and 2001/2002-2003/2004)

Source: Median indirectly standardised 30 day readmission ratios COPD (emergency admissions data pooled for 1998/1999-2000/2001 and 2001/2002-2003/2004)

Figure 2 – The ratio of emergency readmissions within 30 days of discharge for diabetesas a proportion of the population



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Figure 3 – Emergency rates of readmission for COPD within 30 days of discharge as aproportion of the population

The following chart shows that rates of readmission for people with diabetes have increasedsignificantly for all people aged over 50 between 1998 and 2004. The increase in readmissions forpeople over 75 is greatest.

This chart shows that rates of readmission for chronic obstructive pulmonary disease (COPD) hadincreased significantly for people over 75 from 1998 to 2004.


Between 1998/1999-2000/2001 and 2001/2002,there was a small increase in readmissions tohospital following discharge 2003/2004 forpeople with chronic obstructive pulmonarydisease who were between 50 and 64 years ofage but only a slight improvement for peopleaged between 65 and 74 years of age. However,there is a significant increase in rates ofreadmission for people aged 75 years and olderas readmission rates increased by 75%.

The increase in rates of readmission forspecific conditions raises concerns about thequality of planning for discharge andcommunication between the hospital andcommunity health and social services and/orthe quality of community services for peoplewith long term conditions to prevent furthercrisis. It is important that systems arestrengthened to manage the care of people withlong term conditions, particularly older people,so that readmissions to hospital can be avoided.

Services in hospital

Most hospitals have establishedmultidisciplinary teams in wards designatedfor the care of older people. All have identifiedmodern matrons or other nurse leaders with aspecific responsibility for older people.However, in three of the inspected communities,there were no specialist teams that work acrossall wards throughout a hospital to ensure thatolder people receive good care.

Most general hospitals have trainingprogrammes for staff who are caring for olderpeople in general wards but it is evident thatsome staff in general hospital wards requireadditional training to ensure that they treatolder people with dignity and respect andafford them their privacy. This is particularlytrue of staff caring for older people withmental health needs.

Progress against the NSF target to increase the number of intermediate care beds andplaces by March 2002

As at March 31st 2005, there were 29,500 places benefiting more than 360,000 people.

Compared to 1999-2000:

• the number of intermediate care beds had more than doubled

• the number of intermediate care places in non-residential settings had almost trebled

• almost three times as many people benefited from intermediate care

The NHS plan aimed for an extra 6,700 places for intermediate care by March 2005, 5,000residential and 1,700 non-residential places. Communities have delivered an extra 18,095places – 270 % more than the combined target

Source: Statistical Summary to Chief executive’s report to the NHS (May 13th 2005)



Intermediate care at home: redesigning roles in Greenwich

Background

Many services are struggling to recruit andretain staff. This is a particular problem forintermediate care, where in many parts ofthe country there are shortages of suitablyqualified and experienced staff across theprofessions. Making best use of skills andtime is therefore paramount. In Greenwichthis problem is being tackled through thedevelopment of the intermediate care athome support worker role, to workalongside community intermediate careteams to ensure effective delivery of careplans based on outcomes. The main driversfor development of the role include:

• problems recruiting therapists andnurses, coupled with belief thatfrontline support workers could helpmeet this challenge

• the need to develop a more fulfillingand challenging role for some supportworkers, and to formaliseopportunities for career developmentwithin the service

• previous positive experiences ofenhanced support worker roles

• modernisation of Greenwich home care services

• it has the potential to reduce delays,waiting times and duplication intransfers

Twenty posts were recruited from thecouncil’s home care service. Successfulcandidates participated in a three dayinduction and training programme, whichincluded shadowing and placements andstaff now have enhanced skills.

Learning points

Easy access to the rapid response team toget equipment and support from professionalstaff, for example physiotherapy.

Flexible shift patterns developed to help continuity.

Enthusiastic response from staff to thesedevelopments.

A further important development forintermediate care in Greenwich has been therole of the modern matron, who givesprofessional support and clinical supervisionto all the intermediate care facilities providedby an independent sector provider. Themodern matron also supports staffdevelopment and training, the developmentof standardised documentation and providesprofessional supervision.

The future

Development of four senior intermediatecare at home worker posts on a pilotbasis, to offer career progression and aroute into management. The senior rolewill have the opportunity to undertakenational vocational qualifications level 3and 4 (NVQ3/4) and would also pave theway for a similar post to be introducedacross homecare.

Intermediate care

All the inspected communities hadcontributed towards meeting the nationaltarget to increase the availability ofintermediate care, both in designated bedsand at home. They had also increased therange of services to prevent avoidableadmissions to hospital for older people and toreduce delays in discharging patients fromhospital. These findings mirror the nationalpicture, which is illustrated on page 45.

There is some variation in the level of servicesfor intermediate care provided in the 10 localcommunities that were inspected. Not all haveappointed a coordinator in intermediate care tolead the development of services, and access isnot consistent across some of the communities.Health and social care teams are at differentstages of becoming integrated fully. Despite thisvariation, older people generally valueintermediate care. There are some excellentexamples in four of the inspected communitiesof services being reorganised to give olderpeople comprehensive and consistent care,delivered locally. These findings are similar tothose reported by the University of Leeds, 200515

in its recent evaluation of intermediate careservices for older people.

An example of an intermediate care at homeservice in Greenwich is on page 46.

Social care services

The CSCI published a report on the state ofsocial care in December 200516. The findingsof this report on services to older people inregistered care homes and those receiving

services and care in the home present a mixedpicture. Some of the registered care homesinspected were meeting a good proportion ofthe national minimum standards includingtrial visits, relationships, personal space,community contact and having a positiveethos. The biggest improvement from theprevious year was in providing information inan accessible format. However, there wereconcerns in relation to the safety of residents,as many homes did not meet the standardsfor managing medicines, the recruitment ofstaff and safe working practices. In the samereport home care agencies were reported asmeeting 61% of the minimum standards. Areasof concern were lack of flexibility, short visits tousers of services and the terms and conditionsof the employment of home care staff.

Safeguarding older people

The arrangements for safeguarding olderpeople operated effectively in most areas, andmulti-agency policies and procedures hadbeen updated in line with national guidance.Opportunities for training had been developedand staff were generally aware of how abuseoccurred and the action to take when it wasrecognised. However, not all key staff hadreceived training, particularly in the NHS. Mostof the communities that were inspected hadappointed adult protection coordinators,although some had found it difficult to fillposts. Some local authorities needed toimprove the monitoring, reporting and analysisof incidents of abuse and the outcome of theirinvestigations. Adult protection committeeswere in place, although some needed to take atougher approach to setting standards andmonitoring performance.


The Commission for Health Improvement, theformer healthcare regulator, identified sevenkey risk factors for potential neglect andabuse of older people on hospital wards (seebox above). The list was based on 35 clinicalgovernance reviews carried out between 2001and 2003, and two special investigations ofserious service failure at North LakelandHealth NHS Trust in November 2002 and atManchester Mental Health and Social CareTrust in 200317.

Direct payments

Direct payments are payments given toindividuals so that they can organise and payfor the social care services they need.

In several of the inspected communities therewas little take up of direct payments by olderpeople. The national picture, however, shows asharp increase in the number of people aged 65and over taking advantage of direct payments. Thenumber of older people who are using directpayments rose from just 39 to 549 for each100,000 people between 2002 and 200418.

In Wiltshire, older people had been involved indeveloping the mechanisms to help people usedirect payments, and social services hadestablished ‘champions’ in each team to offersupport. The involvement of older people in thisway is likely to lead to a more acceptable approach.

The hallmark of a successful scheme lies in itsflexibility and the availability of tailored supportfor older people. Some local authorities useddirect payments to provide one-off services, forexample to meet the needs of a carer forovernight respite or to meet the needs of olderpeople from black and minority ethnic groups byproviding culturally sensitive home care, or toprovide support to older people who areterminally ill and their carers. In Portsmouth thelocal authority had developed a scheme thatprovided help with recruitment of carers andfinancial advice, and encouraged a pool ofworkers to be available to provide back up.

However, despite training and guidance, somestaff continued to doubt the relevance of directpayments for older people, indicating a needfor further training.



Key risk factors for the potential neglect or abuse of older people

A poor and institutionalised environment.

Low levels of staffing.

High use of bank and agency staff.

Little development and supervision of staff.

Lack of knowledge of incident reporting.

Closed and inward looking culture.

Weak management at ward and locality level.


End of life care

The inspections found an inconsistent pictureof services for end of life care, with welldeveloped, integrated and effective services insome places, but room for improvement inothers. It appeared that, wherever possible,people were helped and supported in theirchoice of place to die. However, the provisionof out-of-hours support was patchy and a lackof practical support may mean that peoplehave to be admitted to hospital or hospice atthe end of their life when they may havepreferred to remain at home.

Supportive and palliative care, underpinned byservices that are person centred, aim to promotephysical, psychological and spiritual wellbeing.The NSF outlines personal and professionalbehaviours which are considered particularlyimportant to end of life care. Services that areneeded to promote dignified and effective end of life care are complex, requiring goodcoordination between organisations. They mustappear seamless to users and carers, be easy toaccess and totally reliable. Some models of bestpractice in end of life care have been developednationally, these are:

• the gold standard framework: thisframework promotes seven key taskswhich focus on improving communication,continuity of care, advanced care planningand support for patients and carers

• the Liverpool care pathway for the dyingpatient: this pathway was developed totransfer the learning from hospices toother settings

• the preferred place of care plan: this is apatient held record of care where the

patient can record information includingchoices about care and other services

Out-of-hours care for older people dying athome was a particular issue for one inspectedcommunity, where there were too fewspecialist nurses to cover a wide geographicalarea, and there was no 24 hour districtnursing service. In another community, anoutreach nursing service from the acutehospital was being developed. In two of the communities that wereinspected there were problems accessingsocial care, partly as a result of difficulties inrecruiting home care workers, and partly dueto lack of clarity about whose responsibility itwas to pay for the social care elements of endof life care. In the latter case the use of apooled budget would help; in anotherinspected community a pooled budget forpalliative care was being set up.

The inspections found a number of differentways of managing medication and pain control.In one inspected community small supplies ofprescribed medication were kept in the homesof patients so that it was readily availablewhere the condition of a patient was expectedto deteriorate rapidly. In addition, specialmedication boxes, which can be used by GPsout of hours, were kept at communityhospitals. These measures helped to ensurethat patients could remain at home safely.

Complaints

Older people saw the way in whichorganisations responded to complaints as veryimportant. This also influenced how likely they

were to complain in the future. Where olderpeople felt that action had been taken torespond to their comments, they weregenerally satisfied. However, if they felt thattheir complaint had been ignored then theoriginal cause of dissatisfaction remained andthey felt even more negative about the servicethat had been provided to them.

One of the reasons why some people said theywere reluctant to complain was the fear thatthis would affect the treatment that they ortheir relatives received. This fear washighlighted repeatedly in the inspections.Other older people were sceptical about thelikely impact of complaining. The results of thesurvey of older people from the communitiesthat were inspected present a mixed picture,with only 27% of older people in one areafeeling that if they made a complaint it wouldbe listened to, while in another, 59% felt theywould be listened to.

There was also concern that systems tomonitor the quality of services failed toinclude the views of people with mentalhealth needs or with learning disabilities. Thiswas seen as a particular problem in servicessuch as home care, where a high proportionof those using the service had some level ofcognitive impairment.

Medicines management

None of the communities that were inspectedwas fully meeting the standards set out in theNSF for the management of medicines. Most general practices are reviewingmedication annually for people aged over 75 but

older people taking four or more medicationsare not always reviewed on a six monthly basis.Some PCTs are employing pharmacists toassist directly in the reviews of medication.Most communities that were inspected are ableto provide some ward based dispensing ofdrugs when the patients are discharged,although this is not available universally.

Seven of the communities were activelyworking to extend the involvement ofcommunity pharmacists in helping olderpeople to manage their own medication.This section has highlighted the need for more progress if older people are to expectservices that genuinely respond to theirunique combination of needs and aspirations.

The following example shows how partnerorganisations in Surrey have successfullyimplemented an electronic singleassessment process.




Developing the electronic single assessment process throughout Surrey

Background

On behalf of its health and social carepartners, Woking Borough Council, obtainedfunding from the Office of the Deputy PrimeMinister for a project, promoting theindependence of vulnerable older people.Part of a national programme Frameworkfor multi-agency environment (FAME), theproject aimed to support several health andsocial care initiatives relating to a range ofservices, including those for older people. Akey aspect of the programme was thesharing of information across public servicesto enable customers to receive relevant,timely and efficient services, whicheveragency they approached. Borough councilofficers, with colleagues from Surrey CountyCouncil, Surrey Heath and Woking PCT,North Surrey PCT, Ashford and St Peter’sHospitals NHS Trust and three generalpractices, developed an electronic singleassessment process, which would benefit allpartners and improve service outcomes forolder people.

A pilot project was established around ageneral practice in West Byfleet andtogether with the technology partnerappointed by the Office of the Deputy PrimeMinister, an electronic single assessmentprocess was developed and tested.Practitioners in health, social care andhousing were involved in reviewing thebusiness processes and workflows linked to the single assessment process, andembraced use of the electronic singleassessment process tool enthusiastically. Theelectronic single assessment process hasenabled the recording, sharing and referring ofinformation in a secure electronicenvironment, with access levels appropriate toindividual practitioners. It is now beingimplemented in Surrey Heath and Woking PCT

Surrey Heath Borough Council and FrimleyPark Hospital NHS Foundation Trust.

Learning points

The electronic single assessment processdeveloped in Woking has made creative useof the Office for the Deputy Prime Ministerfunding for e-government projects. Itsupports the strategic aims of all partnerorganisations, and could be replicated inother health and social care communities.It provides:

• an operational electronic solution thatincorporates the Department of Healthaccredited FACE forms and guidance

• a secure network in which to shareperson identifiable information

• an information sharing protocol

• interface with Anite SWIFT social caresystem and Vision InPractice GP system

• process maps and workflows

• technical specification of requirements

The future

Phased introduction of the electronic singleassessment process throughout Surrey isplanned. The electronic single assessmentprocess infrastructure and technology hasthe potential to facilitate and support otherservice areas, including children, otheradults, mental health and community safety.The fundamental principle of the electronicsingle assessment process is its ability togive partners a shared view of the serviceuser and, in doing so, to avoid duplication ofeffort, provide more focused andcomprehensive assessments and improveoutcomes for older people.


Stroke

“We have been involved in discussions and processes to remodel services; these have transformed what happens. A new strategyhas been produced, and the benefits are seen inbetter informed services, in which patients aretreated as individuals, not stereotypes.”


The services used by people who have suffereda stroke and their experiences in using theseservices is the subject of this section. The NSFhas a standard on stroke services. It is aimedat all people who have had a stroke and is notrelated to age. This section is not restricted tothe national service framework standard onstroke. Stroke was used as a lens throughwhich to assess services against all thenational service framework standards andthemes during inspections. It was clear that alot of effort had gone into improving servicesfor people who have had a stroke, and olderpeople had been part of the process. In somecases, older people had helped to redesignservices, with very positive outcomes. InRedcar and Cleveland, for example, a strokecare coordinator was appointed in response toolder people identifying areas where theirneeds had not been met, and, in Medway, olderpeople had not only been involved in a major

redesign of services, but were part of a processto ensure that services continued to improve.

Also in Medway the use of a diary wasregarded as a valuable and effective means of communication between older people, theirrelatives and friends. The diary could helpthem to remember questions or comments for staff, and to feel more involved in their owncare and treatment.

Specialist services for peoplewho have had a stroke

All general hospitals caring for people whohave had a stroke in the communities that wereinspected provided an acute specialised serviceand operated according to clinical guidelinesapproved by the Royal College of Physicians.

Key messages

Overall, the picture for comprehensiveservices around stroke was improving, withevidence of strong clinical leadership andgood development of both acute services andthose based in the community.

There was equal access to services for people who have had a stroke regardlessof age. Some older people made a specificreference to this as they appreciated thatthere was no age barrier to appropriate careand treatment for a stroke.

All communities inspected provided anacute specialist stroke service.

Three of the communities inspected did notprovide a stroke unit.

All of the communities inspected hadagreed protocols for the referral andmanagement of people who hadexperienced a mini stroke.

Not all of the communities inspected hadstroke registers to identify people at risk ofa first or subsequent stroke.

There were inconsistencies in the way thecommunities that were inspectedimplemented protocols to prevent a first orsubsequent stroke.


A number of factors influenced how well older people recovered following a stroke. For example, the Stroke unit trialists'collaboration (2003)18 showed that spendingtime on a specialist stroke unit greatlyimproved outcomes in terms of death,dependency and the need for institutionalcare. Hospitals in three of the communitiesthat were inspected did not have such a strokeunit open at the time of the inspection. Peoplewho had had a stroke in these communitieswere cared for on general wards with supportfrom the specialised stroke team. A nationalsentinel stroke audit carried out by the RoyalCollege of Physicians in 2004, published inMarch 2005, shows that 82% of hospitals inEngland have a stroke unit20, also more peopleare treated in a stroke unit for part of theirhospital stay compared to the previous year. Inthe communities that were inspected serviceswere not always integrated across health andsocial care.

In some areas access to diagnostics was stillproblematic. MRI (magnetic resonanceimaging) scanners which use radio frequencywaves and a strong magnetic field rather thanx-rays to provide clear and detailed pictures ofinternal organs and tissues – a valuable toolfor diagnosing stroke – were not always fullystaffed, leading to delays. In most places therewas good integrated working, with timelyacute assessment and rehabilitation followinga stroke, and smooth transition from hospitalto home.

Rehabilitation and advice

Rehabilitation and support services based incommunity were established or were beingdeveloped in all areas, with evidence of goodlinks with acute units and effective interagencyworking providing a rapid response service.Many older people and their carers spokehighly of such services, particularly the inputfrom therapists and the speedy provision ofequipment and adaptations to the home toenable independent living. However, follow upby GPs was not always as effective as it mightbe. Medication was not always explainedclearly, and some carers said that GPs wereoften unaware of the caring role andresponsibilities they undertook.

Several people singled out the Stroke Associationfor praise, mentioning the information providedand its excellent volunteers who helped peoplenavigate through the complex system forbenefits. One older person commented “whenillness strikes people are at a low ebb and leastable to cope with the bureaucracy involved inaccessing services and benefits. Skilled help atsuch a time is vital and valued”. A survey carriedout by the Healthcare Commission and theRoyal College of Physicians21 in 2005 found thatalmost one third of patients who wantedinformation from health and social servicesabout stroke said that they had not received anysince they left hospital.

A national sentinel stroke audit carried out bythe Royal College of Physicians in 2004 foundthat 65% of people who were admitted tohospital had a physiotherapy assessmentwithin 72 hours of admission and 52% had anassessment by an occupational therapist

Stroke continued


within seven days of admission. However,respondents to a survey in 2005 following theirdischarge from hospital found that peoplewere more negative about the rehabilitationprovided to them after discharge, whencompared to the 2004 survey about theexperiences of patients in hospital.

Awareness and prevention

PCTs in all but one of the communities thatwere inspected had agreed protocols with theirGPs for referring and managing people whohave had a transient ischaemic attack(otherwise known as a mini stroke). However,not all general practices in all communitieshave established stroke registers of people atrisk of stroke because of high blood pressure orother factors. Stroke registers can help topinpoint individuals at risk of stroke, build up alocal picture of care and treatment for strokeand assist development of prevention plans(integrated with acute and community services),and identify and support carers. As such, theyare an important addition to the effectiveprevention, care and treatment of stroke.

There is evidence of inconsistency in somecommunities in the ways people who hadalready had a stroke were being treated tominimise the chance of them having a secondstroke. Further work is needed to ensure that allgeneral practices are aware of and are workingto agreed protocols for managing people at riskof both a first and subsequent stroke.

The inspections found very littleacknowledgment of the important role playedby services that could contribute towardspreventing stroke, such as leisure and

exercise services, although many were keen to develop their involvement.

A report by the National Audit Office, Reducingbrain damage: faster access to better strokecare22 suggests that awareness of stroke and itscauses is poor among the general population,with three quarters of people surveyed havinglittle or no knowledge of the risk factors, andmost people not associating the Stop Smokingcampaign with stroke, believing it to be relatedsolely to the prevention of cancer. Similarly,there was little awareness of the significance ofhigh blood pressure as a risk factor for stroke.

The workforce

Some communities that were inspected wereaddressing issues around the workforcecreatively and to good effect, with evidence ofeffective integrated working across agencies.Overall, staff said that they had access totraining that was of good quality, with jointtraining taking place in many areas. Most staffhad access to induction and ongoing trainingfor stroke care and treatment. In Medway theemployment of stroke rehabilitation assistantswas having a positive effect on the servicesprovided, enhancing partnership working andoptimising input of the various team members.The assistants, who were well regarded bytheir coworkers, offered a more flexible serviceto older people, and helped to maximise theeffective use of professional therapy staff. Theywere extending their role by running exercisegroups, breakfast meetings and library runs,and were developing a programme of visits toolder people once they left hospital, thusproviding continuity, and a person centredservice.


Falls

“Mum had one fall but I didn’t know how to contact people. The second time she fell I had the control centre number and they rang my mum on the intercom. She fell again and theparamedics came. Services where going to be arrangedwhen she was discharged, but then they decided shewould go into home.”


This section reviews services provided to olderpeople who have had a fall or are at risk ofhaving a fall. A fall in later life can result in abroken hip. There is a risk that without propercare and treatment this could lead to poormobility, a lack of self confidence and socialisolation. There is an national serviceframework (NSF) standard on falls but thissection looks more widely at falls servicesacross all of the NSF standards and crosscutting themes.

There were inconsistencies in themanagement and review of services aroundfalls. For example, there was an expectationthat protocols for dealing with falls to be usedby all partners should be developed. Wherecommunities had developed such protocolsthese were not routinely reviewed to checkwhether they were used by all partners or tomeasure the impact of their use.

The NSF states that NHS organisations,working in partnership with local authorities,should take action to prevent falls and reducethe resulting fractures or other injuries inolder people. Older people who have fallenshould receive effective treatment andrehabilitation and, with their carers, receiveadvice on prevention through a specialistservice. Milestones to be achieved included anaudit of procedures; putting in place riskmanagement procedures by all localhealthcare providers (health, social servicesand the independent sector), inclusion inrelevant local plans of the development of anintegrated service around falls, and theestablishment of an integrated service byApril 2005.

Key messages

Progress on developing integrated fallsservices was limited, with just two of the 10communities that were inspected having aservice in place.

Of the remaining eight communities, threedid not have a strategy to develop anintegrated service around falls and one

community had a strategy but no fallscoordinator.

Lack of a strategy, or of clear lines ofaccountability, mean that the development ofan integrated falls service was not given ahigh enough priority.


Components of an integrated falls service – Department of Health

1. Agreeing and implementing local priorities to reduce the incidence and risk of falls.

2. Ensuring appropriate initial assessment and response (for example to an emergencydepartment or through intermediate care services, where the need for hospitalassessment is not required) to those who have fallen.

3. Having a multidisciplinary falls team, so that people with recurrent falls, or one fallwith serious consequences, have access to specialist assessment to identify and reducerisk factors for further falls and manage the consequences of the fall.

4. Having an osteoporosis service, and in particular diagnostic scanning, to reduce therisk of osteoporotic fracture and long term impact of falls.

5. Having rehabilitation services for those who have lost functional ability or confidenceafter a fall.

An Audit Commission review of progressagainst the NHS plan in 2003 found that only4% of trusts had achieved the target toestablish an integrated service around falls.While 62% of trusts were rated as ‘at low riskof failure’, 34% of trusts were rated as ‘at highrisk of failure’.

Many of the inspections found a lack ofinvestment in services to address falls withlittle commitment beyond the introduction of‘sloppy slippers’ programmes (projects toreplace ill fitting slippers with ones that fitproperly to help reduce the number of falls).Examples of good practice did exist, but,where these were identified, they weregenerally developed in isolation rather thanthrough a coordinated strategic approach,leading in many cases to uneven provision ofservices across a community. Some of thecommunities that were inspected wereexploring ways to ensure prevention is

prioritised in future. For exampleBuckinghamshire’s community plan for 2006-2008 will include at least two targets aroundprevention, trips and falls, and safety in thehome which will be cross cutting themes acrossthe local authority. The role of local authoritiesin making sure that pavements and public areasare safe, and in offering opportunities forexercise to improve strength and balance wasnot recognised as part of a whole systemapproach to the prevention of falls.

While there was a drop in the number of olderpeople admitted to hospital for fractured neckof femur (broken hip) between 1999/2000 and2000/2001, the number between then and2003/2004 steadily increased. Overall, therehad been an increase of 4.1% between1999/2000 and 2003/2004. This indicates thatprogrammes for preventing falls have not yethad any effect on reducing admissions tohospital for a broken hip.

Falls continued


Rates of mortality for falls were higher in themost deprived areas compared to moreaffluent ones. This means that when olderpeople were admitted to hospital following afall, those in deprived areas did not recover aswell as those in more affluent areas.

A common theme was the failure ofcommunities to use data to inform thecommissioning and provision of servicesaddressing falls. Some communities simply didnot collect data, for example on the needs of,expenditure on, or outcomes for older peoplewho had fallen or were at risk of a fall. Otherscollected the data but it was not good enoughto be relied on, or, where it was of good qualityit was not used. However, ambulance servicescollected a wealth of information that couldand should be used by partner organisations tohelp target resources. For exampleinformation collected by the ambulanceservice on where and how people fall could beused to target action on falls prevention suchas medical assessment for undiagnosedconditions, pavement repair, improved lightingin public places or fitting a stair rail in aperson’s house. Analysis of data held by theambulance service had started in oneinspected community, and this had exposedincreasing levels of need that the falls teamwas, at that time, insufficiently resourced.


Mental health

“The nurses said they weren’t qualified to deal with that kind of patient (older peoplewith mental health problems). But it seemed tobe as if most of the patients were that ‘kind’.”


This section is about services for older peoplewith mental health needs. There is a standardin the national service framework aboutmeeting the needs of this group. However,during the inspections we used mental healthas a lens through which to assess all servicesused by older people with mental healthneeds and their experiences of these services.This section reports on the findings fromthese inspections.

The national service framework states thatolder people who have mental health needsshould have access to integrated mentalhealth services, provided by the NHS and localauthorities, to ensure effective diagnosis,treatment and support for them and theircarers. The inspections found that there waslimited progress in providing an integratedservice to older people with mental healthneeds. Only four of the communities that wereinspected had integrated community mentalhealth teams for older people.

There was often no shared vision across healthand local authorities for older people withmental health needs, leading to inadequatejoint commissioning arrangements and a poorrange of services. Some areas had developed astrong strategic vision and integrated plans, butlack of resources made it difficult to turn thevision into reality as many mental healthservices for older people were reported to bechronically under funded. Out-of-hours andcrisis management services were particularlyaffected, with older people experiencingvariable levels of provision. These services weregenerally less well developed than thoseavailable to working age adults.

There was wide variation in the ways in whichmental health services were provided, evenwithin areas, with many differentorganisations involved. These arrangementswere often based on historic structures andwere characterised by poorly developed linksbetween the various service providers, leadingto fragmentation and a piecemeal approach to

Key messages

Most inspected communities werestruggling to deliver a full range ofintegrated, good quality services to olderpeople with mental health needs.

There was a lack of out of hours and crisismanagement services for older people.

There was poor care on general hospitalwards (when admitted for physical illnessor injury) as staff do not have the skills

and experience to care for older peoplewith mental health needs.

There were inadequate intermediate careservices for older people with mentalhealth needs who require rehabilitationfollowing physical illness or injury.

There was little evidence that services arebeing developed to promote good mentalhealth, for example tackling loneliness andsocial isolation.


service planning and delivery. The goal of aperson centred approach, with servicesdesigned around the older person, has stillnot been reached for older people with mentalhealth needs.

Dementia and depression

Dementia affects more than 750,000 people inthe UK – one person in 20 over the age of 65and one person in five over the age of 80.Similarly, it is estimated that at any one time10-15% of the population aged over 65 sufferfrom undiagnosed and untreated depression,with all the distress and impact on quality oflife and physical health that this brings(Moriarty 1999)23. The inspections found thatwhile there was local agreement to the use ofprotocols for treatment of dementia anddepression, use of these was not alwaysconsistent. Older people in most communitiesexpressed concerns about the care andtreatment that older people with dementiareceived when admitted to hospital for aphysical illness. Staff on acute wards werefrequently incapable of managing the needs ofthis particular group, having inadequate

understanding of the condition, or of thedisorientation caused by strangeenvironments and multiple moves.

People were not receiving adequate orsensitive help with eating and, as a resultmeals were being taken away uneaten. This has serious implications for nutrition,which is known to be a significant factor in theprocess of physical recovery. However, inBuckinghamshire this training need had beenrecognised and a new programme for staffhad been implemented.

Intermediate care

The inspections found inadequate or nointermediate care services for people withmental health needs, particularly dementia.This means that people miss out onrehabilitation and the chance to return home.It has been estimated that three quarters ofolder people in care homes are affected bydementia. Many of them might have benefitedfrom programmes of rehabilitation tailored totheir needs, had these services beenavailable. An evaluation of intermediate care

Buckinghamshire – South Bucks Dementia Project

Winner of the Queen Mother’s Award forHealth and Social Care, this project providestailored services, which enable older peoplewith dementia to remain, and be cared for,at home. This has provided continuity ofcare and environment for older people andreduced the need for hospital admission.

The project has grown steadily since itsinception in 2003, taking nearly 100referrals in the year to April 2005.

Health and social care teams work effectivelytogether, providing a valuable service forpeople with dementia and their carers.

Mental health continued


for older people carried out by LeedsUniversity in 2005 also found that older peoplewith mental health needs were being excludedfrom intermediate care. Models ofintermediate care for people with cognitiveproblems should be developed to help thembenefit from rehabilitation.

There were some examples of good practice inwhich the mental health needs of older peoplewere being addressed in a sensitive andcoherent manner.

For carers of older people with mental healthneeds the lack of community services,particularly crisis response, patchy access toappropriate respite or short break care andpoor integration with other parts of the healthand social care systems, sometimes led topressure and strain. In Medway, the olderperson’s partnership addressed this issue byusing reimbursement funding to providesupport services for carers of people withdementia – a good example of the creativeuse of resources.

In two of the communities that wereinspected, Leicester and Buckinghamshire,inspectors found examples where specialisthome care services provided support tailoredto older people with mental health needs andtheir carers.

Carers of people with mental healthproblems reported that information andadvice were often available in non-stigmatising ways from the voluntary andcommunity sectors, and also from someskilled professionals. Some carers describedreceiving good quality statutory services thatmade a real difference in unfamiliar andworrying situations.

Activities and opportunities aimed specificallyat maintaining mental health for older peopleare under developed. Many of the activitiesaimed at promoting general health andwellbeing, contribute towards good mentalhealth. However, the inspections found littleevidence that communities were developingsystematic ways of tackling loneliness andsocial exclusion among older people in orderto promote good mental health.


Living well in later life

“Crossing the road helped to bringback my confidence; the more youget out the better.”


This section covers the spectrum of servicesand opportunities that contribute towards thewellbeing and independence of older people aswell as the extent to which partnerorganisations are working to draw thesetogether into coordinated strategies to improvewellbeing. It touches on the contribution madeby the services that all groups are likely to useto some extent, such as public transport, aswell as the wide range of initiatives in areassuch as leisure and learning, that aimspecifically to improve the health andwellbeing of older people. It also focuses onthe support and care services that aim to helpolder people, who are frail, to live asindependently as possible in the community.

A minority of communities, usually led by thelocal authority, are developing strategies forolder people that focus on citizenship andinclusion and incorporate the wide range ofservices and issues that make a difference to the lives of older people. This growing trend is in line with national policy, as well as with the views of older people. Howeverthese strategies were at an early stage ofdevelopment, so it was too soon to commenton their impact on older people.

There was increasing interest from localstrategic partnerships, the large partnershipbodies led by the local authority, that bringtogether a wide range of partner agencies to

Key messages

In almost all communities, a range ofactivities were available, but not as part ofan explicit, coordinated approach topromoting the wellbeing of older people.

Strategies on wellbeing were at an earlystage, although there were signs of agrowing interest in this area, including fromlocal strategic partnerships.

Older people emphasised the importance ofcontributing to the community, eitherformally, through a range of groups andactivities, or informally, through helpingfriends, family and neighbours.

In almost all the inspected communities,except for a small number of inner cityareas, older people highlighted transport asthe key obstacle to their independence andwellbeing. However, only a few inspected

communities were able to show that theywere taking coordinated action to tackle this.

Community safety and fear of crime werealso key concerns for older people, andsome innovative local initiatives have beendeveloped. However, only a few inspectedcommunities were addressing the concernsof older people, or involving older people indiscussions on this issue.

Exercise classes and other opportunitiesfor healthy living were widely available and valued by older people, as was thelibrary service.

For frailer older people, services arecontinuing to shift towards providing a greater proportion of care at home,so that older people can continue to liveindependent lives.


agree and implement priorities for the localarea. One local strategic partnership wasfocusing on the prevention of falls, ensuringthat older people have adequate heating intheir homes and access to libraries. Anotherrequired all its subgroups, which look atissues such as crime or the environment, toconsider systematically how their decisionsaffect older people.

Only a small minority of the communities thatwere inspected had explicit priorities for olderpeople included in the community strategy,the overarching partnership strategy producedby the local strategic partnership. Thesetended to relate to social care targets, ratherthan to the aspirations of older people. Incounty areas, there is evidence of districtcouncils becoming more involved with PCTpartners, in promoting the health andwellbeing of older people.

The findings from the inspections areconfirmed by early messages from the firstpilots of the Audit Commission’s newapproach to comprehensive performanceassessment (CPA) – the inspection processthat assesses the performance of councils.From 2005, the comprehensive programmeapproach includes an element on thewellbeing of older people, and the pilots foundthat the understanding of councils andactivities in this area were variable. Of thethree pilot councils, one had recentlypublished a strategy for older people that wasbased on the priorities of older people, onewas carrying out preliminary work and thethird had not yet started to consider the needsand aspirations of older people except in thecontext of care services.

Making a contribution

Many older people were actively involved intheir local community. Older peoplehighlighted the important role that they play inmanaging and delivering services andactivities. For example, a social centre in oneof the inspected communities was run in partby older people from the Indian communitywho had taken over premises from the localauthority. Inspectors also met with a relativelynewly established African group for olderpeople that was working on a self help basis,with local authority support.

Older people said that spending time withothers is an important part of maintaining anactive life. The role of groups was particularlyvalued by those who had special needs interms of language or disabilities, but alsobecause they were often isolated, such asVietnamese older people or older Africans,people who had been deaf since their youth,people who had a visual impairment and oldergay men and lesbians. Such support and selfhelp groups help to promote the wellbeing ofolder people. For example, a social group ofsouth Asian women took its members onoutings locally, to the seaside and on holidaysabroad. A member said: “We get fresh air, achance to get out of the house and our mindsbecome fresh.”

“I am the DIY man [in my blockof flats] for example if there’s[someone] who can’t changethe light bulb I do it for them.’’

Living well in later life continued


Although not everyone was interested inbecoming involved formally with local groupsand organisations, many helped familymembers, friends and neighbours throughinformal arrangements, emphasising theimportance of interdependence.

Transport

Older people suffer disproportionately froma lack of access to transport and olderpeople are less likely than others to have acar. Transport therefore plays a crucial rolein the lives of older people and theyrepeatedly stressed its importance. In ruralareas poor bus services made it difficult forthem to lead full social lives or to travel tohealth services, so isolation was an issue insome rural communities.

Problems with public transport were notconfined to the countryside, however, as olderpeople in some cities, towns and suburbs allmentioned this as an important issue.Criticisms included limited services,particularly in the evenings, buses that were

unsuitable for older people with mobilitydifficulties, and slow, indirect routes. InLondon, the free travel pass, the FreedomPass, was much appreciated by older people,and viewed with envy by older people in otherareas. In Liverpool, too, older people spokepositively of the local concessionary travelarrangements. Most transport strategies,however, failed to take the needs andaspirations of older people explicitly intoaccount and did not involve older people inplanning transport services.

Crime and community safety

Most inspected communities were takingaction to address crime against older people.In some cases this was as part of a generalinitiative that benefited the whole community,such as ‘alley-gating’ (installing security gateson the alleys behind terraced housing in orderto reduce burglary and other crimes). Inothers, developments targeted older peoplespecifically, such as initiatives to tackledistraction burglary or rogue traders. Thesewere often delivered in partnership withtrading standards departments.

Some community safety partnerships includedrepresentatives from local older people'sgroups to ensure that older people had a voicein discussions on community safety priorities.In other areas, however, the particular impactof fear of crime on the lives of older peoplewas not well recognised.

The surveys of older people in the inspectedcommunities found that older people hadconcerns about their personal safety,

“I looked after my mother whohad Alzheimer’s for 15 yearsand she died four yearsago…That is why I joined theAlzheimer’s Society. I alwaysfeel I’m putting back whathelp I got with my mother.”



especially in the evenings. This affects theirquality of life and wellbeing. Older peoplereported their experiences of feeling unsafe,being subject to crime and a lack of personalsecurity, both within their homes and in publicspaces. Some of these reflected feelings thatthe areas where they lived were undergoingchange, as long established communitiesbecame more fragmented, and that localpolicing was inadequate. However, the surveyshowed that the confidence of older people ingoing out alone in their area varied considerablyacross the inspected communities. In one ruralcounty, 82% of older people felt safe, while inan inner city area, this was only true for 55%of the older people surveyed.

There were some more positive reports ofolder people benefiting from initiatives to tacklecrime and fear of crime, such as providingtransport from evening entertainment, and theinstallation of locks and security devices. An example of this is given below.

Regeneration and housing

A number of inspections took place in areaswhere there had been major investment inregeneration, and also in areas where therewas much expansion, new build and growth.In communities where major regenerationinitiatives were underway, there did notappear to be a good understanding of thespecific concerns of older people, nor anysystematic way of giving older people a voicein discussions about regeneration. In Medway,however, the council was encouraging privatedevelopers to market new apartments to localpeople over 50, as well as to younger people,to create a balanced community in whichpeople of all ages felt welcome.

In most of the communities inspected therewere strong links between services for olderpeople and the Supporting people programme,the initiative that aims to improve and develophousing related support to vulnerable groups.Although resources were an issue, there was anaspiration to use Supporting people as a way ofdeveloping more innovative ways of helpingolder people to remain in their own homes. TheSupporting people inspections, which are beingcarried out by CSCI and the Audit Commission,found that Supporting people had stimulatedmany communities to review the focus andpurpose of sheltered housing, in order tomaximise the benefits to older people.

Most communities were commissioning extracare sheltered housing (housing that providescare services on site) but this was not alwaysintegrated within a wider vision for health andsocial care services.

The Wiltshire ‘Bobby Van’

The Wiltshire Bobby Van Trust is aregistered charity comprising vans withdrivers, which operates across thecounty and carries out repairs to thedoors and windows of older people whohave been victims of crime. The driversare trained in victim support and crimeprevention. The Bobby Van was the firstproject of its kind in the country and itsimpact has been significant, as therehave been no repeat burglaries in theproperties visited by the project.


Healthy living

In all the inspected communities there wereusually many initiatives aimed at healthy livingfor older people. Older people valued these,but they rarely added up to a shared strategicapproach to the wellbeing of older people.Although many excellent initiatives were inplace that older people valued, services werenot consistent and access was patchy.

Leisure, lifelong learning and library serviceswere all providing services tailored to peopleover 50, ranging from exercise classes andwalking groups to training in computer skills. Provision was often fragmented anddisconnected from health and social careservices. There was no overview of all theopportunities and services that existed,potentially leading to duplication or gaps inprovision. In addition, older people rarelyreceived information on the whole range ofservices, including leisure or learningopportunities that could make a real differenceto their lives. Local strategic partnershipswere beginning to address the need foroverarching strategies, with specific referencein some to the needs of older people.

Some leisure facilities were only open atrestricted times for older people who usedconcessionary rates. The survey carried out by King’s College London as part of theinspection process, showed that only aminority of respondents felt that their localleisure services were attractive to olderpeople, ranging from 24% to 31% across thecommunities surveyed.

Some inspected communities were alsocreating opportunities for older people andyoung people to work together onintergenerational projects using arts,reminiscence or other methods tostrengthen understanding and respectbetween the generations.

The surveys of older people showed thatlibraries were well used as a source ofinformation by older people. In some areaslibraries provided a tailored service for peoplewith disabilities. For example the libraryservice was reported as very good for peoplewith a visual impairment. In some communitiesa talking books service was available andhighly valued. Older people also appreciatedbeing able to renew books from home.

Although many older people participated inlearning opportunities, the survey showed thatonly between 20% and 28% of older peoplesaw these as relevant to them.

All of the communities that were inspected coulddemonstrate an increase in the numbers ofpeople over 60 who had stopped smoking. This isin keeping with national trends as Department ofHealth statistics on NHS Stop smoking servicesshow that the number of people 60 years andover setting a quit date increased by 113.8%between 2001 and 2005. Of those who set a quitdate and were successful there is also anincrease of 5% between 2001 and 2005.

A minority of the inspected communities wereable to show that they were maintaining ormonitoring blood pressure levels in people atrisk of heart attack or stroke.



There has been a small increase in thepercentage of people aged 65 and over whohave been vaccinated against flu. There is agap between the percentage of older peoplevaccinated against flu in the most deprivedareas (69.8%) and in the least deprived(72.2%) (figures for 2003-2004 taken fromCompass screening database).

Living independently

Care services in the communities that wereinspected were continuing to move towardssupporting frailer older people to liveindependently at home. There was also areduction in the number of people admitted tocare homes. This matches the national picture– see figures 4 and 5.

1998/1999 1999/2000 2000/2001 2001/2002 2002/2003 2003/2004

12.0

10.0

8.0

6.0

4.0

2.0

0.0

Figure 4 – Households receiving intensive home care per 1,000 population aged 65 and over

Source: Department of Health performance and assessment framework (PAF) data 2005

1998/1999 1999/2000 2000/2001 2001/2002 2002/2003 2003/2004

140.0

120.0

100.0

80.0

60.0

40.0

20.0

0.0

Figure 5 – Supported admissions of older people to residential and nursing care per10,000 population aged 65 and over

Source: Department of Health performance and assessment framework (PAF) data 2005


In all the inspected communities, partnerorganisations were working together toincrease the number of older peoplesupported at home. A range of services andinitiatives were in place to contribute towardsthis. In one area, an intermediate care servicehad successfully helped older people to moveback to living independently even after theyhad spent some time in residential care.There was warm praise from older people forservices that aimed to help them to liveindependent lives. In particular, intermediatecare services were valued highly.

While many communities and partneragencies were clearly finding it difficult torefocus services towards independence andwellbeing, others had made significantprogress in this direction. Merseyside Fire andRescue Service had worked proactively toreach out to older people and to bring in othersupport from partner agencies, if required.Their approach goes beyond a narrow focuson fire safety to look at the range of issuesaffecting older people’s independence andwellbeing. The work by the service was also underpinned by recognition of thecontribution older people make to improvingsafety in the home.

An example of illustrative practice byMerseyside Fire and Rescue Services isgiven at the end of the next chapter.

“We are happy and proud to live here.”


Leading organisations through change

“A nurse comes every fortnight to take blood samples from my mother. Myfather, who needs the same, because he ismore mobile, he has to go to the hospital.Why can’t the nurse do both?”


This section looks at the ways in whichpartner organisations were working togetherto improve services for older people. It setsout the extent to which partner agencies hadclear shared goals and describes thestructures and processes that they used toachieve these. It examines how successfulcommunities have been in offering a balancedrange of services and opportunities for olderpeople. The section also looks at the factorsthat help change occur across a wholesystem, including having a shared way ofmonitoring progress, systems to check thatmoney is used wisely and for making good useof information across agency boundaries, and

high calibre, well trained staff to deliverservices to older people.

Very few of the communities that wereinspected had attempted to work togetherwith older people to agree what they wantedto achieve with and for them. A shared visionfor older people that brought together all themany issues contributing to the wellbeing ofolder people (as distinct from a vision forhealth and social care services alone) was juststarting to emerge in some of the inspectedcommunities. There was evidence of a shift inperspective on older people in some localauthorities, generally at a very senior level,

Key messages

In some inspected communities a sharedvision was starting to emerge in partnerorganisations, based on the priorities ofolder people, but in most cases this wasnot translated into explicit strategies,action plans or commissioning decisions.

Leadership of the older people’s agendawas noticeably stronger in local authoritiesthan in the NHS.

Many partnership bodies were in a state offlux and governance and accountabilitywere often unclear.

Good partnerships at a strategic level wererarely accompanied by equally goodpartnerships between frontline staff (orvice versa).

Joint commissioning was under developedin all inspected communities. While someservices were commissioned jointly, thesedid not form part of a joint commissioningstrategy.

None of the inspected communities had ashared system across partner agencies tomonitor progress and impact.

Pooled budgets, which would allow creativeuse of shared resources, were under used,and there was limited evidence thatresources were being used effectively tolever change, particularly in the NHS.

None of the inspected communities had ajoint workforce development strategy and,although there were some innovativeinitiatives, these did not form part of awider shared approach to workforce issues.


although this was not always reflected lowerdown the organisation, or within partneragencies, particularly the NHS. There wastherefore no shared sense of direction oroverarching goal for the work of partneragencies that guided how resources wereused or priorities decided.

Only one of the 10 communities that wereinspected was about to produce a sharedstrategy on older people. This had beendeveloped through the local strategicpartnership and was being consulted on at thetime of the inspection.

The lack of a shared direction across partneragencies had implications in a number ofareas. For example, the experiences of olderpeople were that the services were confusingand incoherent. Those who planned serviceswere not clear what they were trying toachieve. The example in figure 6 illustrateshow one London borough, with its partnersand with older people, is setting the directionfor older people in their local area. Thisincludes a focus on health and social careservices, but in the context of a much broaderapproach that emphasises wellbeing andsocial inclusion.

The inspections highlighted a discrepancy inthe strength and effectiveness of leadership

on the issues of older people between localauthorities and the NHS. Within localauthorities, there was a growing commitment,both from senior officers and from electedmembers, to improving the wellbeing of olderpeople, and within this, to improving careservices. All could demonstrate that serviceshad shifted significantly in recent years, withmore older people able to remain at home,and less use of residential care. At a seniorlevel in local authorities and among electedmembers there was a growing understandingof the local authority’s community leadershiprole in working with its partners, to buildcommunities in which it is possible to age well,and in some areas, strategies were underdevelopment that reflected this new thinking.

Within the NHS, however, the picture was lesspositive. The inspections highlighted examplesof poor treatment of some older people inhospitals, of unequal access to some servicesand of variable involvement of older people inservice planning, and these suggest that olderpeople are not seen as a high priority by someNHS staff. Similarly, the narrow focus onmeeting NHS targets on waiting times andreducing delayed discharges from hospital,sometimes at the expense of delivering goodservices to other older people, showed alimited understanding of the connectionsbetween the two. People aged 65 and over usetwo thirds of general and acute hospital beds.As the main users of hospital services itmakes sense to improve the quality of serviceprovided to older people as this will in turnhelp NHS trusts to achieve other NHS targets,including waiting times. Partnership workingbetween local authorities and the NHS is likelyto remain difficult until both partners

“Money has gone into thehospitals, but no money hasgone into the basic services,where it’s badly needed.”

Leading organisations through change continued


recognise the importance of improvingservices for older people, and acknowledgethe benefits this will bring to the NHS and tothe local authority, as well as to older people.In some of the inspected communities, thestructures and groups in place to developpartnership working were in transition. Local implementation teams that had been setup to oversee the implementation of the NSFwere changing their focus, for example bytaking on a commissioning role. The changesaffecting services for children were also having

an impact on the approach for older people,with some communities setting up or exploringthe possibility of establishing partnershipboards for older people. These were typicallysubgroups of the local strategic partnership,and operated in parallel with the recentlyestablished partnership boards for children.

The extent to which the independent sectorwas involved in planning services for thefuture was variable, and in a number ofinspected communities these organisations

Figure 6 – Key objectives of ageing well in Lewisham

Valuing older peopleRecognise the value of the input that older people make to the life of Lewisham byintegrating older people into mainstream activities, including decision-making.

FinanceEnhance the financial security of all older people to enable them to play a full part in thelife of Lewisham by improving information on benefits, concessions and other financialservices, and enabling them to remain economically active for as long as they wish.

HealthKeep people as independent as possible for as long as possible by improving preventiveservices, and in the event of failing health, to provide high quality acute health and supportservices with choice and flexibility.

A safe environmentEnhance the feeling of safety and security both within the home and outside by providingaccessible and affordable housing, accessible and safe transport systems and a safeenvironment.

Lifelong learningEnsure that older people have full access to learning opportunities and information andthat they are encouraged to pay a full role in the learning of others, giving of their skills,experience and knowledge.

RelationshipsEncourage intergenerational working as widely as possible; challenge age discriminationand promote a positive image of older people.



said they wanted a stronger voice inpartnership working.

The complexity of partnerships was an issue insome areas, particularly in large county areaswhere there were also district councils. Therewas sometimes confusion about the decisionsthat were taken at a local or a countywidelevel, as the various groups and structures didnot clearly connect with each other.

Strong partnership working at a strategic,whole system level was not always mirroredby effective partnerships in the way thatservices were delivered. Partnerships weredescribed as strong at both strategic andoperational levels in only one community thatwe inspected, Redcar and Cleveland.

The variability of partnership arrangementsfor older people reflects findings from theAudit Commission that blurred lines ofaccountability within partnerships can lead topoor value for money.

The lack of a strong sense of directionaffected the ability of inspected communitiesto take strategic commissioning decisionstogether in order to achieve shared goals.Joint commissioning was not well developedin any of the communities that were inspectedand there was little evidence of partneragencies working together in a planned way to refocus services over time, usingcommissioning as a tool for change. In mostcases there were examples of jointcommissioning of individual services orinitiatives taking place between social servicesand PCTs. However, this was rarely in thecontext of a shared commissioning strategy

for older people, although a number ofcommunities were working on these at thetime of the inspections.

In addition, the fragmented and inconsistentpicture of services that emerged from theinspections indicated that learning and goodpractice were not being spread, nor datashared in order to target resources effectively.

This picture is reinforced by the findings of the2004/2005 inspections of services for olderpeople that were carried out by CSCI. Theyfound that, of the 18 social servicesdepartments inspected during the year, onlythree had joint commissioning strategies withthe NHS and only one had fully integrated itscommissioning with the PCT.

Development of joint commissioning will needto include the Best value principles ofchallenge, comparison, consultation andcompetition, together with that of contestability– the notion of competitive provision, with thepossibility of services being switched fromprovider to provider, and failing providers exitingthe market – thus using competition to widenchoice and improve performance and quality ofservices for older people.

Voluntary organisations commented ondifficulties caused by short term funding forthe services they provided, and late notificationof funding decisions. This made planning andstaffing of services difficult to sustain.

The Department of Health’s white paper Ourhealth, our care, our say sets out plans for anew joint commissioning framework forhealth and social services supported by an


alignment of the planning and budgeting cyclefor the NHS with local government planningand budget setting. The recent guidance fromthe Government on commissioning a patientled NHS will provide new opportunitiesopening up the market of health and socialcare to a wider range of providers includingthe independent sector.

None of the inspected communities haddeveloped measures jointly to gaugeperformance and the impact of the variousservices within their local communities. Cost and quality information was not beingused systematically to shape services.Individual organisations had their ownperformance management and qualityassurance frameworks, but without wholesystems frameworks it is difficult to knowwhether services are:

• achieving their aims and predictedoutcomes for older people

• being provided in the right quantity

• having a negative or positive impact onother services

It is also impossible, without information fromacross the system, to identify gaps in theprovision of services, or to regularly measureoutcomes across health and social care, and touse that data to inform future planning. Therewere some examples of work that had thepotential to act as a platform for furtherdevelopment. Local area agreements were seenas a way of building a better understanding ofthe performance of whole systems performancein a number of communities, and in one,partners were about to agree sharedperformance indicators for older people’s

services. In another, extensive use had beenmade of pooled budgets. All initiatives funded inthis way were jointly performance managedacross the NHS and the council.

There was some use of financial flexibilitiessuch as the pooling of resources across theNHS and local authorities, made possible bysection 31 of the Health Act 1999, whichintroduced a number of new partnershiparrangements. About half of the inspectionsites were using the opportunities provided forpooled budgets, most commonly for integratedcommunity equipment services. There waslittle evidence that partner organisations werestarting to align budgeting processes.

Local authorities had developed processes forensuring they obtain value for money, as partof the Best value programme, but theseprocesses were not seen in health services.There were no systems in place in the NHS to monitor spending by age across differentservices. This meant that it was not possibleto identify how much was spent on olderpeople across the NHS, and therefore tomeasure impact of investment on outcomes. It was also difficult to build a complete pictureof investment in older people across the wholecommunity and thus to take an overall view ofhow resources needed to shift in order toachieve service change. Local areaagreements may help to provide this picture.

The inspections highlighted a number offactors that made whole system working moredifficult. These are common themes that donot appear to have shifted significantly inrecent years:

• financial pressures



• lack of clear decision-making inpartnerships

• incompatible IT systems

• organisational change

• different NHS and local authorityboundaries

• different priorities for partners,particularly the emphasis by the NHS on meeting targets for waiting times

• little sharing of knowledge on what works well

Workforce issues

None of the communities that were inspectedhad a joint workforce development strategy;workforce planning was fragmented andopportunities for joint training, buildingcapacity and the development of new ways ofworking, such as generic health and social careworkers, were not being used widely. A few of

the communities inspected were developing thegeneric health and social care assistant role,but this was not widespread.

Some organisations were experiencingsignificant recruitment difficulties, particularlyfor home care and therapy staff, and theseinevitably affected their ability to provideservices of sufficient quality and quantity. Thelack of a joint approach contributed to theseproblems. Individual agencies that target thesame pool of staff wastes resources and sets upunnecessary and undesirable competition. Insome instances poor terms and conditions anddifferential pay scales deepened the problems.Workforce planning developed on a singleagency basis has an impact on other agenciesacross the whole system and is unhelpful

Older people highlighted the inadequate skillsof some home care workers, with peoplecommenting that many home carers did notknow what the work demanded. Young careworkers, in particular, were mentioned; there

Tackling recruitment and retention of key staff in Cambridgeshire

The National Skills Council, in partnershipwith the Open University and UNISON,developed a work-based foundation degreeto help develop a health and social caregeneric workforce. This work area, with lowpay and poorly developed training structures,often attracts people with few academicskills. To incentivise the scheme, entrantsare taught literacy and numeracy skills –known to be relatively low in East Anglia. Thenormal national vocational qualifications

(NVQs) are available to these staff but allowaccess only to a nursing qualification, not tothe specialist professions such asoccupational therapy. This programmeallows progression to a foundation degreeafter basic NVQ, and then into qualificationssuch as occupational therapy, physiotherapyand social work, or even to specialise inconditions such as diabetes and coronaryheart disease. Seventy people went throughthe project in its first year.


is high turnover, they do not know what isexpected of them and are ill equipped to copewith the demands and pressures of the job.Often, workers were not paid to attendtraining sessions.

The approach of Merseyside Fire and RescueService goes beyond a narrow focus on firesafety to look at the range of issues that affectthe independence and wellbeing of olderpeople. These services are also underpinnedby the recognition of the contribution of olderpeople to improving safety in the home.



Merseyside Fire and Rescue Service

“The knock-on effects of this work have been huge – the message is now that it’s aboutmeeting the needs of older people, it’s not just about fitting smoke alarms.”

Background

In Merseyside, a high percentage of firedeaths were among older people. It wasclear that older people would need specialattention to reduce deaths and that firefighters did not have the right skills ornetworks to carry out this work. Theservice has developed innovative ways ofreaching out to older people in Merseyside.Fire safety has become one of a range ofservices in Merseyside that can help olderpeople live independently and safely.

Advocates for older people

In 2003, the fire service appointed a team ofspecialist advocates to raise the profile of firesafety in the community and to work withpeople at highest risk. Five of the advocateswork with older people and people over 60were encouraged to apply for the posts.Advocates have been successful in buildingnew partnerships with councils, the NHS, thepensions service and older people’sorganisations. They offer fire safety advice toolder people in various settings – in the localhospital, for example, as part of dischargesupport, and in outpatient departments. Theyvisit sheltered housing and social clubs,emphasising the important contributionolder people themselves can make byspreading the message to friends andneighbours. Reaching older people who maynot be in touch with any services is a priority.

Fire support network

In 2000, the fire support network wasestablished in Merseyside. A voluntaryorganisation, and supported by £570,000 in

funding from the Home Office’s activecommunities unit, it support’s the work ofthe fire service, including generating firesafety checks in 8,000 homes each year.Around 85% of the 150 volunteers are olderpeople. One initiative in which oldervolunteers have been particularly active isthe After fire care project, in which they helpto clean up smoke damage, restoretreasured items such as family photos andrefer people to other agencies.

Learning points

Establish a ‘can do’ culture whichencourages innovation at all levels – changecan happen in advance of formal strategies.

See failure as an opportunity to buildlearning.

Be clear about the purpose of partnershipsand the expected outcomes.

Ensure that managers model new ways ofworking and have a visible role in newdevelopments, to give clear messages tostaff about the importance of change.

Base developments on good data, targetinterventions and track impact.

Recognise skills gaps and be creative aboutthe sort of people who might fill them.

The future

Increase understanding of the impact of fire on physical and mental health, in addition to fire deaths, as a lever forstronger engagement by the NHS.

Fire deaths have fallen from 25 to less than10 per year. The aim is to reduce this further.


Conclusions


This concluding section summarises thefindings of the local community inspections,and highlights three key areas that requirefurther action, without which sustainableimprovement in the experiences of olderpeople of public services is unlikely to beachieved. These are:

• Tackling discrimination, ageist attitudes andincreased awareness of other diversityissues.

• Ensuring that all of the standards set outin the national service framework (NSF)are met, including those in the Next stepsreport from the Department of Health dueto be published in April 2006. Moreinformation summarising the progressagainst the NSF and identifying specificareas for further action is provided at theend of this section.

• Strengthening working in partnershipbetween all the agencies providingservices for older people to ensure thatagencies work together to improve theexperiences of older people that use public services.

This section is followed by recommendationsfor further action to ensure that services usedby older people continue to improve.


Explicit age discrimination has declined sincethe NSF was published, as a result of NHStrusts auditing policies on access to services andsocial services reviewing their criteria, eligibility.These are criteria a local authority uses toprioritise who receives social care services.

Access to cardiac procedures and hip and kneereplacements have improved since the NSFwas published. Between 1999 and 2004 thenumber of hip replacements carried out onpeople aged between 65 and 74 increased by39% and for people aged 75 years and older, itincreased by 22%. According to hospitalepisode statistics from the Department ofHealth, there has been a general increase inhip and knee replacements for the wholepopulation but the increase is still significantfor older people. The exception to this declinein explicit discrimination is mental healthservices, where the organisational divisionbetween mental health services for adults ofworking age and older people has resulted inthe development of an unfair system, as therange of services available differs for each ofthese groups. For example out-of-hoursservices for psychiatric advice and crisismanagement for older people are not asdeveloped as those for adults of working age.Older people who have made the transitionbetween these services when they reached 65have said that there were noticeable differencesin the quality and range of services available.

Despite these changes there is still evidence ofageism among staff across all services. Thisranges from patronising and thoughtlesstreatment from staff, to the failure of somemainstream public services, such as transport,to take the needs and aspirations of olderpeople seriously. Many older people find itdifficult to challenge ageist attitudes and theirreluctance to complain can often mean thatnothing changes.

We found that some older people experiencedpoor standards of care on general hospitalwards, including poorly managed discharge


from hospitals, repeated moves from one wardto another for non-clinical reasons, beingcared for in mixed-sex bays or wards andmeals being taken away before they could eatthem due to a lack of support at meal times.All users of health and social care servicesneed to be treated with dignity and respect.However, some older people can beparticularly vulnerable and it is essential thatextra attention is given to making sure thatcare givers treat them with dignity at all timesand in all situations. To fail to do this is aninfringement of their human rights.

There is a deep rooted cultural attitude to ageing, where older people are oftenpresented as being incapable and dependentparticularly in the media. As there is anincreasingly ageing population, there is a needfor policy makers and those who plan anddeliver public services to consider the impactof ageism and to take action to address this.

During our inspections of local communities,we also found that awareness of diversityissues was at an early stage of development,with more work required to ensure that olderpeople from black and minority ethnic groupsreceive services that are culturally sensitiveand responsive to their needs. The high levelsof morbidity and mortality from certaindiseases and the difficulties of access andappropriate and responsive services have beendocumented well in relation to black andminority ethnic groups. There is a need toimprove information and communityengagement and to have detailed informationabout the needs of the population whenplanning services. Appropriate steps should betaken to form partnerships with the local black

and minority ethnic groups that representolder people to ensure that this group of olderpeople is fully engaged in the planning anddevelopment of services. Organisations whichcommission or provide care and socialservices should take account of diversity in allthey do and take account of cultural andreligious needs, and embed this understandinginto mainstream services for older people.

Sadly, there are occasions when older peopleexperience abuse and neglect by the peoplewho are supposed to be caring for them. It isimportant that this risk is minimised. This canbe done by health and social care staff beingaware of how and when abuse and neglectcould occur and by taking action if it isidentified. We found that the arrangements forsafeguarding older people operated effectivelyin most areas with multi-agency policy andprocedures. However, there is still room forimprovement. It is vital that health and socialcare organisations continue to address this toensure that opportunities for abuse andneglect are minimised, and when they aredetected, they are acted on.

Meeting the standards set outin the national serviceframework

The National Service Framework for OlderPeople, and the developments in policy that followed followed, have placed anunprecedented focus on services used byolder people. The inspections found a greatdeal of activity to improve the experiences ofolder people of public services. Staff in

Conclusions continued


partner organisations were working togetherto establish new initiatives and new ways ofworking to do this. There has been progress ina number of areas.

Explicit age discrimination in access toservices has been addressed by most healthand social care services. All of thecommunities inspected as part of this reviewhad made a significant effort to ensure thatpolicies and eligibility criteria did notdiscriminate against older people. The AuditCommission’s review on national progressagainst the NHS plan found that 76% of NHStrusts had reviewed their criteria for eligibilityto services as required by the NSF.

More good quality care than ever before isavailable to people who have had a stroke. All ofthe general hospitals caring for people whohave had a stroke provided a specialist strokeservice, which operated according to the clinicalguidelines for best practice approved by theRoyal College of Physicians. Seven of the 10communities inspected also had a stroke unit.The National sentinel stroke audit carried outby the Royal College of Physicians in 2004,published March 2005, showed that 82% ofhospitals in England have such a unit and morepeople were treated in these units for part oftheir hospital stay than in the previous year.

The number of older people who have had fluvaccinations has increased. There has been a2% increase in people over 65 beingvaccinated against flu between 2002 and 2004.

The number of older people who have stoppedsmoking has increased. All of thecommunities inspected could demonstrate an

increase in the number of people over 60 whohad stopped smoking. This is in keeping withnational trends which show the number ofpeople aged 60 and over who set a date tostop smoking increased by 113.8% between2001 and 2005, and of those who set a quitdate and were successful, there was anincrease of 5% for the same period.

More people are being supported to live athome. Health and social care services werecontinuing to move towards supporting olderpeople who are frailer to live at homeindependently. There was also a reduction in thenumber of older people admitted to carehomes. This matches the national picture whichshows that the number of households receivingintensive home care, per 1,000 of the populationaged 65 and over, has steadily increased fromeight to 11 between 1998 and 2004 (Departmentof Health Performance Assessment Frameworkdata 2005).

All of the communities inspected coulddemonstrate a reduction in delayeddischarges from hospital over the past twoyears. The Department of Health’s statisticsshow that there has been a 67% reduction indelayed transfers of care from 5,396 in 2001 tojust 1,804 in 2005.

There is a growing interest in the widerwellbeing of older people, with services suchas leisure and culture playing an increasinglyimportant role, and strategic partnershipsspearheading some innovative partnershipdevelopments.

The National Service Framework for OlderPeople has led to some positive achievements


but there is further work to do to meet thestandards set out in the NSF. The key issues inneed of further action identified as a result ofthis review are detailed below:

• The full implementation of the singleassessment process across health and localauthority partners.

• Older people should have a copy of theirassessment and personalised care plan. Achange in culture is required, moving awayfrom services being service-led to beingperson-centred, so that older people have acentral role, not only in designing their carewith the combination and type of service thatmost suits them, but also in planning therange of services that are available to allolder people.

• All aspects of mental health services forolder people need to improve includingperson-centred care, age equality in therange of services available, treatingpeople with dignity and respect, holisticcare in mainstream services and a wholesystems approach to the commissioningof integrated mental health services forolder people.

• Integrated falls services are at an earlystage of development and more work isneeded for them to progress including the five components of an integrated falls service as set out by the Departmentof Health.

• The management of medicines needs to beaddressed, as many older people receivingmore than four medications are still notreceiving a review every six months.

NHS trusts and local authorities need to worktogether to ensure that they are reviewingtheir progress against the NSF as part of aframework for managing performance.

Supportive and palliative care, underpinned byservices that are person-centred, promotephysical, psychological and spiritual wellbeing.The NSF outlines personal and professionalbehaviours which are considered particularlyimportant to end of life care. Services that areneeded to promote dignified and effective end oflife care are complex, requiring goodcoordination between organisations. They mustappear seamless to users and carers, be easyto access and be totally reliable. We found thatthe provision of services for people at the end oftheir life was inconsistent, with integratedsystems that were developed well in someareas but showing room for improvement inothers. The provision of out-of-hours supportwas patchy and a lack of practical support maymean some people have to be admitted tohospital or hospice care at the end of their lifewhen they may have preferred to die at home.


There are examples of some excellent workingin partnership both at a strategic andoperational level. However, few of thecommunities inspected had a shared sense ofwhat they wanted to achieve with and for olderpeople, or how progress would be measured.

This lack of a clear direction resulted infragmented services that confused older

people. The range of services that was availablediffered significantly between communities, andeven within a single community.

Sustainable change cannot take place unlessall partner organisations have a shared viewof the direction in which they want to move,and how they plan to get there. Earlierresearch from the Audit Commission hasshown that this shared vision has a powerfulrole to play if it is rooted in the views of olderpeople. When older people are asked aboutthe priorities that would most improve theirlives, these often relate to issues beyondhealth and social care services, such ashaving a neighbourhood which is safe, accessto transport, an adequate income andopportunities to meet with others. Therefore,visions and strategies for older people mustreflect these needs.

A lack of shared direction results in a poor use ofresources and a commissioning process thatdoes not encourage change. It also results in theprovision of an inconsistent and uncoordinatedrange of services.

There was evidence of some engagement with older people but they were not involvedsystematically in the design of services, norwere services tailored to their needs andaspirations. Health organisations and localauthorities were not always effective inengaging with black and minority ethnicgroups, and with older people whose voicesare seldom heard.

While we found that some of the communitieswere implementing the NSF in innovative ways,these were not available consistently to older

people, nor was learning from these initiativesshared or implemented more widely. Only ifpartner organisations work together to agree ashared vision and to map out a pathway toachieve this, will older people be able toexperience services that are well planned andjoined up. New initiatives from the Departmentfor Work and Pensions, the Department ofHealth and the Social Exclusion Unit that aimto test integrated responses to older peopleand learning from the SureStart initiative forchildren, will offer useful experience on whichto build.

Most of the communities we inspected had ajoint workforce development strategy. Workforceplanning was fragmented and opportunities forjoint training, building capacity and thedevelopment of new ways of working, such asgeneric health and social care workers, were notbeing used widely. A few of the communitieswere developing the health and social careassistant role but this was not widespread.Some organisations were experiencingsignificant difficulties in recruitment. The lack ofa joint approach contributed to more problems.

Conclusions continued



Challenges and recommendations

This section identifies key areas for action byNHS and social care providers andcommissioners of services and local authorities.Many of the recommendations require theseorganisations to work in partnership. We alsohighlight areas for further work by centralGovernment and regulators. These actions areessential to ensure the continuing improvementof services for older people.


1. While progress has been made by healthand local authorities in systematicallytackling age discrimination, through auditsof policy, and the reviewing of eligibilitycriteria, there is still evidence of agediscrimination and ageist attitudes, whichhave had an impact on the lives of olderpeople. These include the discriminationolder people sometimes experience whenreceiving care services that fail to treat themwith dignity and respect. Managers of NHStrusts, social services and providers ofindependent health and social care had toensure that the human rights of olderpeople are upheld at all times.

2. The needs of older people including thosefrom black and minority ethnic groups are not always recognised. NHS trusts, localauthorities and providers of independenthealth and social care need to ensure thatall staff receive full and ongoing training ondiversity issues, including attitudes toageing, so that older people are treated withrespect. They should respect diversity in allthat they do, taking account of cultural andreligious needs, and embed thisunderstanding into mainstream services.

3. Progress has been made in establishingadult protection committees with anincreased awareness in healthcareorganisations and local authorities of theneed to safeguard older people. However,there is more to be done. NHS trusts,social services and providers ofindependent health and social care need to:

• review the operation of adult protectioncommittees

• promote effective working in partnership

• ensure that information is comprehensive,

• ensure that the management ofperformance is effective

• implement policies and proceduresthrough training through training that areeasily accessible

Meeting the standards set out in the national serviceframework

4. The National Service Framework (NSF) forOlder People provides a 10 yearprogramme for the improvement ofservices for older people. Good progresshas been made in some areas. However, anumber of the standards have not been metwithin the timescales of the NSF. NHStrusts and local authorities need to takeaction to ensure that the standards set outin the NSF for older people are met,including the Next steps update due to bepublished in April 2006 and the Departmentof Health’s Older people mental healthservice development guide.



5. Wherever possible older people aresupported to receive end of life care in theplace in which they choose to die.However, sometimes a lack of appropriatecommunity services means that they haveto be admitted to hospital. There is a needfor partner agencies to use the bestpractice models of end of life care toensure that older people and their carersreceive prompt access to well coordinatedand effective care and respect at the endof their lives.


6. The effectiveness of partnershiparrangements for services for older people is improving. However, partnerorganisations should ensure thatpartnerships have robust governancearrangements with clear lines ofaccountability in line with the LocalGovernment Act 2000.

The Act places a duty on every localauthority to prepare a strategy for thecommunity to link all their strategic plansand to manage partnerships through a localstrategic partnership. Strategicpartnerships working for and with olderpeople should include all the organisationsthat commission and provide services usedby older people, as well as older peoplethemselves. This review has demonstratedthe importance of a joined up approach toplanning, commissioning and deliveringservices that takes account of all of the

factors that are important to the health andwellbeing of older people. Older peoplehave an important contribution to make inthe shaping of services to ensure that theyrespond to their needs and aspirations.Providers of independent health and socialcare are also important partners within thestrategic partnership, as they bringinnovation and the potential to provideadditional resources.

7. There has been some progress inpromoting health and wellbeing for olderpeople but this has not been the result ofa joint strategy with a coordinatedapproach across health and localgovernment. NHS trusts, local authoritiesand providers of independent health andsocial care need to work together todevelop the promotion of good health andwellbeing. The Department of Health’swhite paper, Our health, our care, our say,published in January 2006, has reinforcedthe role of the director of adult social careworking with the director of public health,in undertaking regular joint reviews oflocal health needs.

8. Partner organisations are workingtogether to develop a shared vision forservices for older people. However,organisational change has slowed downprogress in taking this forward, partly asa result of the health policy Shifting thebalance of power, published in 2001,which changed the roles of healthauthorities and PCTs. There is a need forpartner organisations to translate theshared vision into a shared strategy for

services for older people and to use thisto inform joint commissioning. Thisshould result in a comprehensive andcoordinated range of services to meet theneeds of the local population.

9. Partner organisations are engaging witholder people. However, there is not asystematic and coordinated approachthat makes best use of resources.Partner organisations need to worktogether to ensure that there is asystematic and coordinated approach toengagement that recognises the diversityof the population being served.

10. Some partner organisations are workingtogether to tackle recruitment and retentionof staff. However many do not and so theyare targeting the same small pool of staffand creating unhelpful competition in theemployment market. NHS trusts and localauthorities need to work together to developjoint workforce strategies to become moreeffective in recruitment and retention acrosshealth and social care services.

Further work for centralGovernment

Some of the progress needed to improveservices used by older people can only comeabout through support from centralGovernment, particularly in three areas. These are:

1. Following on from Opportunity age, theGovernment needs to develop a cross-Government national programme of work to help shape a more positive culture onattitudes to ageing.

2. National standards and improvementmeasures have supported the improvementof the performance management of healthand local authorities. However, theperformance of individual organisations toachieving national targets sometimesconflict with improving the outcomes forolder people across a whole system of care.For example, the requirement for acutehospital trusts to reduce waiting times forelective (planned) surgery has resulted inPCTs commissioning a disproportionateamount of acute hospital servicescompared to community services that couldprevent emergency admissions to hospital.The Department of Health’s White paperOur health, our care, our say makes acommitment to align how health and localauthorities are being assessed on theirperformance. This should include thedevelopment of ways to measureoutcomes for older people based on theperformance of all partners workingtogether.

3. Older people would like to see improvedaccess to podiatry and general foot care.Poor foot care can lead to poor mobility andresult in both a loss of independence andsocial isolation. The Department of Healthcould support improved access to goodquality podiatry and general foot careservices by requiring PCTs to commissionadequate provision of those services.

Challenges and recommendations continued



Further work for the HealthcareCommission, the Commissionfor Social Care Inspection andthe Audit Commission

As well as organisations that provide servicesfor older people and central Government, it isalso important that the Healthcare Commission,the Commission for Social Care Inspection andthe Audit Commission take action to ensure thatthere is continuous improvement of services forolder people and the momentum from thisreview is continued.

Developing policies and tools at a nationallevel, which will help to support the localimplementation of the National ServiceFramework for Older People, is essential.

The Healthcare Commission, the Commissionfor Social Care Inspection (CSCI) and theAudit Commission, as the regulatory bodieswith responsibilities for assessment acrosshealthcare, social care and local government,will be taking the following actions, inconsultation with partner organisations:

1. The Commission for Social CareInspection will monitor progress againstthe recommendations in this reportthrough the annual assessment ofcouncils and the inspections of socialservices for older people.

2. The Audit Commission will monitorprogress against the recommendations in this report through the older people’sstrand of corporate assessment, which is part of the Audit Commission’s

comprehensive performance assessmentof local authorities.

3. As part of the Healthcare Commission’sannual assessment of the performance ofNHS trusts – the annual health check – theHealthcare Commission will continue tomonitor progress against key nationaltargets, for example those relating tosupporting older people to liveindependently at home. The requirement totreat all patients with dignity and respectwill be assessed as part of the annualhealth check against the Department ofHealth’s core standard on patient focus.The requirement to take the views of olderpeople and their carers into account indesigning, planning, delivering andimproving healthcare services will also beassessed by the Healthcare Commissionagainst the Department of Health’sstandard on accessible and responsive care,as will access to services.

4. The three commissions will developimprovement activities targeted at issuesidentified by this review. This includesdeveloping and delivering a jointCommission for Social Care Inspection/Healthcare Commission review of mentalhealth services for older people.

5. Joint indicators will be developed to supportimprovement in key areas, including thoseareas where progress has been the slowest.These indicators will form part of theongoing assessment of health and socialcare organisations and will be used to lookat how services are improving year on year.

Challenges and recommendations continued

The indicators will be developed in line withbroader frameworks for assessingperformance which are focused onoutcomes outlined in Our health, our care,our say and will be used to underpinimproved partnership working through thedevelopment of local area agreements.

6. The Healthcare Commission currentlysupports a programme of national clinicalaudits. Audit projects aimed at improvingthe quality of clinical care and improvingoutcomes in services for older people willcontinue to be reflected in this programme– which currently includes audits of servicesfor people who have had a stroke, servicesfor people who have fallen and services forpeople with incontinence.



Moving forward


This report is presented at a time of continuedchange for services for older people and asustained focus on its findings andrecommendations will be required for lastingimprovement. The Healthcare Commission,CSCI and the Audit Commission arecommitted to playing a central role inensuring that the findings of this joint piece ofwork are taken forward to improve servicesfor older people.

The three commissions have shared theemerging findings of this report with partnerorganisations including the Department ofHealth, the Department for Work andPensions, Better Government for OlderPeople, the Local Government Association andothers to ensure that the conclusions of thisreport are reflected in:

• Our health, our care, our say – a newdirection for community servicesDepartment of Health (January 2006)

• A SureStart to later Life – endinginequalities for older people, a SocialExclusion Unit Final Report (January 2006)

• the implementation arrangements forOpportunity age and LinkAge Plus

• work on the shared priority on olderpeople between national and localgovernment

The joint inspections of services for olderpeople were one of the first collaborativeinitiatives across a number of regulatorybodies. This review aimed to build a completepicture of all the services across ageographical area and the extent to whichthese work together as a well coordinated

whole system to improve the lives of localpeople. This approach is likely to becomeincreasingly important in the future, asregulators build a more sophisticatedunderstanding of the way in which the totality ofservices combine to make a difference to qualityof life. The Healthcare Commission, CSCI andthe Audit Commission are committed toensuring that the learning from the jointinspections helps to shape inspection and thatthe findings of this review contribute towardsimproving the lives of older people in the future.

Findings against the standardsset out in the national serviceframework and areas forfurther action

The National Service Framework (NSF) forOlder People was published in 2001. It is a 10year programme for the improvement ofservices for older people, with standards andmilestones for delivery. At the time of thereview (2005), all of the milestones shouldhave been reached. Progress against themilestones set out in the NSF has beenassessed as part of this national review ofservices used by older people. Evidence hasbeen drawn from the 10 local communitiesthat were inspected and from supportingnational data, as set out in the body of thisreport. Specific areas requiring action arementioned under each standard, based on thefindings of this review. However these are notcomprehensive and organisations need toassure themselves that they are achieving allof the standards set out in the NSF.


Standard 1 Rooting out age discrimination

NHS services will be provided, regardless of age, on the basis of clinical need alone.Social care services will not use age in theircriteria for eligibility or policies to restrictaccess to available services.

Healthcare organisations and social serviceshad made significant efforts to ensure that policies and criteria for eligibility do notdiscriminate against older people. Theexception to this was in mental health servicesfor older people where the organisationaldivision between adults of working age andolder adults has resulted in an unfair servicebeing provided to older people compared tothat for adults of working age. Older peoplestill experienced discrimination through theageist attitudes of some staff in providing andplanning services. There is a need for partneragencies to ensure that ageist attitudes areaddressed as a programme of long termchange and that mental health services forolder people are reviewed to ensure that theyare not disadvantaged. They should do this bymapping the provision of specialist health andsocial services provided to older people withmental health needs.

Health and social care organisations did notalways support older people’s champions andso are not getting the full benefit from theseposts. NHS trusts and social services need toensure that the local network of olderpeople’s champions is fully supported withinformation, training and communicationfacilities to enable them to be effective in

ensuring that the needs of older people aremet in the planning and delivery of services.

Standard 2 Person centred care

The NHS and social care services treat olderpeople as individuals and enable them to makechoices about their care. This is achievedthrough the single assessment process,integrated commissioning arrangements andintegrated provision of services, includingcommunity equipment and continence services.

Good progress was made in implementing acommunity equipment and continence service,although older people in some areas reporteddelays in obtaining equipment. In fourcommunities there were integrated continenceservices across all partner organisations. Theothers were at varying stages of developingintegrated continence services.

NHS trusts and local authorities wereimplementing plans to introduce a singleassessment process and many have beenpiloting different models to help make aninformed decision. However, the timescales inthe NSF had not been met for implementingone model of the single assessment processacross the community. The inspections foundthat, while older people were generallyinvolved in planning their care, choice was limited by the range and flexibility of services.

Organisations had made variable progress inchanging the ways they behaved and worked,


Moving forward continued

so that all older people are not yet genuinelytreated as individuals with particular needsand aspirations.

NHS trusts and social services need to worktogether to implement the single assessmentprocess fully and to promote its benefitswidely in all organisations that are in contactwith older people.

Standard 3Intermediate care

Older people will have access to a new rangeof intermediate care settings to promote theirindependence, by providing enhancedservices from the NHS and council to preventunnecessary hospital admission, and effectiverehabilitation services to enable earlydischarge from hospital and to preventpremature or unnecessary admission to longterm residential care.

This is an area where significant progress hadbeen made as the growth of intermediate careservices had exceeded the Government’s targetin the NSF. Delays in transfers of care haddecreased considerably and more people withcomplex needs were being supported to live athome. Unfortunately, alongside the reduction indelayed discharges from hospital, theinspections found that many older people stillexperienced poorly managed arrangements fordischarges from hospital. NHS trusts and socialservices need to improve the experiences ofolder people being discharged from hospital.They also need to build on good practice bydeveloping intermediate care services further to

provide managed networks of care for peoplewith complex needs. Intermediate care serviceswere generally unable to meet the rehabilitationneeds of older people with dementia who haveexperienced disease or injury. There is a needfor hospital and community services to developa range of intermediate care approaches thatcan meet these more complex needs.

Standard 4 General hospital care

Older people’s care in hospital is deliveredthrough appropriate specialist care andhospital staff who have the right set of skillsto meet their needs.

Most general hospitals had specialistmultidisciplinary teams, although the localinspections found that these teams did notalways work across all specialties. However,we found that the basic care needs of olderpeople were sometimes not met in hospitaland older people with mental health needs didnot always receive holistic care when admittedto a general hospital. There is a need forhealth service managers and managers ofcare homes to ensure that all staff in regularcontact with older people learn how to carefor people with mental health needs and toensure that basic care needs are met.

In addition, hospital managers should payparticular attention to ensuring that:

• older people are not required, even whenthere is pressure surrounding availablebeds, to receive care in wards or bays thatdesignated for the opposite sex


• older people are not moved from ward toward for reasons other than clinical ones

• staff maintain good nutritional standardsby assisting older people who are unableto eat and drink independently, and by ensuring that meals are not missed bypatients who are taken from the ward forinvestigations and treatment (unless theyare required to fast)

Standard 5 Stroke

The NHS will take action to prevent strokes,working in partnership with other agencieswhere appropriate. People who are thought to have had a stroke have access to diagnosticservices, are treated appropriately by aspecialist stroke service and subsequentlywith their carers, participate in amultidisciplinary programme of secondaryprevention and rehabilitation.

Services for people who have had a strokehave improved. Community and hospital-based services have been developed well.More people were receiving care in a stroke unitfor more than 50% of their stay in hospital andprotocols were in place between hospitals andGPs for the referral and management of peoplewho have had a mini stroke. However, not all ofthe communities had such a unit and therewere inconsistencies in the way protocols wereimplemented to prevent a first or subsequentstroke. We also found that stroke registers werenot being used in all communities to identifypeople at risk of having a stroke.

Primary care trusts and acute trusts need toensure that people who have had a strokereceive care as set out in the Royal College ofPhysicians guidelines, and in particular shouldensure that every acute trust has a stroke unit.NHS trusts, local authorities and independentproviders of health and social care need toaddress the prevention of strokes as part of thewider agenda on healthy communities. Thequality and outcome framework for GPs mayhelp to increase the use of a stroke register.PCTs need to ensure that this is used as part ofa prevention programme.

Standard 6 Falls

The NHS, working in partnership with localauthorities, takes action to prevent falls andreduce fractures or other injuries in theirpopulation of older people. Older people whohave fallen receive effective treatment and,with their carers, receive advice onprevention through a specialist falls service.

There were reports of some excellent models of integrated services dealing with falls acrossthe country, however this is not yetwidespread with only two of the communitieshaving integrated services for dealing withfalls. NHS trusts, local authorities andproviders of health and social care need to setup integrated falls services where these donot exist. These services should coordinatethe initiatives of the many organisations thathave a role to play in preventing falls, andsupporting people who have had a fall toregain their independence.

Moving forward continued


Standard 7 Mental health in older people

Older people who have mental healthproblems have access to integrated mentalhealth services, provided by the NHS andlocal authorities to ensure effectivediagnosis, treatment and support for themand their carers.

There were good local partnerships involved inplanning and delivering mental health servicesto older people. However mental healthservices for older people were generally underdeveloped and reported to be poorly resourced.Mental health services for adults of workingage were managed separately from those forolder people and this resulted in an unfairservice for older people with mental healthneeds. There was also little evidence of workbeing done to promote good mental health inold age.

The promotion of good mental health shouldbe part of a wider health promotion andwellbeing programme that recognises theimportance of social inclusion, leisure andlearning opportunities and the contributionthat older people make as valued members of the community.

Standard 8 Living well in later life

The health and wellbeing of older people is promoted through a coordinatedprogramme of action led by the NHS, with support from councils.

Local authorities were providing exercise,leisure, libraries and learning opportunities,which were valued by older people. There wasan increase in people over 60 who hadstopped smoking, and an increase in fluvaccinations for older people. Some GPs weremaintaining or monitoring blood pressurelevels in people at risk of a heart attack orstroke. However, there was no strategic andcoordinated programme of action that broughttogether the public health and wellbeingagenda across health and local government to promote healthy active life in old age andpartner organisations need to work togetherto achieve this goal.

Medicines management

Ensure effective management of medicinesso as to improve health.

PCTs were working with communitypharmacists to review medication and toprovide more information to older people toenable them to manage their own medication.However GPs were not carrying out reviewsevery six months of older people taking fouror more types of medication. PCTs need toaddress this by ensuring that plans are inplace to move towards this standard and thatprogress is regularly reviewed and reported.


References

1. National Service Framework for OlderPeople, Department of Health, March 2001

2. Our health, our care, our say: a newdirection for community services,Department of Health, January 2006

3. Opportunity age, Department of Work andPensions, March 2005

4. Independence, wellbeing and choice,Department of Health, March 2005

5. Achieving the NHS plan – assessment ofcurrent performance, likely future progressand capacity to improve, AuditCommission, June 2003

6. Socio-economic and demographicpredictors of mortality and institutionalresidence among middle aged and olderpeople: results from the longitudinal study:Journal of epidemiology and communityhealth, Breeze E, Sloggett A, Fletcher A,December 1999, vol 53: 765-774

7. Submission to the independent enquiry oninequality in health. Input paper, transportand pollution Davis A, 1998

8. Integrated services for older people:building a whole system approach acrossEngland, Audit Commission, 2002

9. Productive ageing: an overview of theliterature. Journal of Ageing and Socialpolicy, 6 (3); 39-71, O’Reilly P, Caro FG.1994

10. Statistical summary to Chief Executive'sreport to the NHS, May 13th 2005

11. Community Care Act, Department ofHealth, 2003

12. Leaving hospital revisited, CSCI, October2005

13. Leaving hospital the price of delays, CSCI,2004

14. Changing times: improving services forolder people, a report on the work of theChange Agent Team 2003/2004

15. An evaluation of intermediate care for olderpeople, final report, Institute of HealthServices and Public Health Research,University of Leeds, 2005

16. State of social care in England 2004-2005,CSCI, December 2005

17. Evidence to the health select committeeon elder abuse 2003 based onCommission for Health Improvementinvestigation at North lakeland HealthNHS Trusts and Manchester MentalHealth and Social Care Trust

18. Department of Health performance andassessment framework (PAF) statistics2005 source: PSS PAF C51

19. Stroke unit trialists’ collaboration,The Cochrane data base of systematicReviews 2003

20. National sentinel stroke audit 2004,Royal College of Physicians’ Clinicaleffectiveness and evaluation unit, March 2005

21. Caring for people after they have had astroke: follow up survey of patients,Healthcare Commission, March 2006

22. Reducing brain damage: Faster access tobetter stroke care, National Audit Office,November 2005

23. Use of community and long term care bypeople with dementia in the UK: a review ofsome issues in service provision and carerand user preferences. Ageing and mentalhealth Moriarty JM 1999 3(4): 311-319

References continued



Appendix A: Meetings with keystakeholders

The project team for this review met with the following organisations to consult on the scopeof the national review:

Age Concern

Alzheimer’s Society

Ambulance Service Association

Association of Directors of Social Services

Better Government for Older People (BGOP)

British Geriatric Society

Black Minority Ethnic Elders

Carers UK

Care Services Improvement Partnership Change Agent Team

Chartered Society of Physiotherapy

College of Occupational Therapy

Dementia Voice

Department Of Health

Department for Work and Pensions

Department for the Environment and RuralAffair (DEFRA)

English Community Care Association (ECCA)

em POWER – the Charities consortium ofusers of prosthetics, orthotics, wheelchairs,electronic assistive technology andrehabilitation

Help the Aged

Help the Hospices

Health Development Agency

MIND

National Osteoporosis Society

National Patient Safety Agency

NHS Modernisation Agency

NHS Wales and the Welsh Assembly

Office of the Deputy Prime Minister (ODPM)

Policy Research Institute on Ageing andEthnicity (PRIAE)

Royal College of Nursing

Royal College of Physicians

Royal College of Psychiatrists

Royal College of Speech and LanguageTherapists

Royal Pharmaceutical Society

Royal National Institute for the Blind

Royal National Institute for the Deaf

Society of Local Authority Chief Executives

The Stroke Association

Appendix B: Policy changes andinfluences since the national serviceframework


Policy changes

Our health, our care, our say: a new direction for community services, Department of Health,January 2006

A sure start to later life: ending inequalities for older people, Office of the Deputy Prime Minister,January 2006

Commissioning a patient led NHS, Department of Health, September 2005

Independence, wellbeing and choice, Department of Health, March 2005

Opportunity age, Department for Work and Pensions, March 2005

Putting people at the heart of public services, Office of Public Services Reform, 2005

Improving services, improving lives: evidence and key themes, Social Exclusion Unit Office of the Deputy Prime Minister, 2005

Supporting people with long term conditions. An NHS and social care model to support localinnovation and integration, Department of Health, 2005

Choosing health: making healthier choices easier, Department of Health, November 2004

Community Care Act 2003, Department of Health

Information strategy older people, Department of Health, March 2002

Fair access to care services, Department of Health, 2002

NHS funded nursing care, Department of Health, October 2001

Building capacity and partnership in care, Department of Health, October 2001

Local vision – a 10 year vision for local government, Office of the Deputy Prime Minister, 2005


Race Relations (Amendment) Act 2000

Disability Discrimination Act 2005

Good practice guidance

The business of caring, King’s Fund inquiry into care services for older people in London, 2005

Older people, independence and wellbeing, Audit Commission/Better Government for OlderPeople

Link-age, Department for Work and Pensions, 2004

All our tomorrows: inverting the triangle of care, Association of Directors of Social Services/LocalGovernment Association, 2003, ADSS/LGA, 2003

No secrets: Guidance on developing and implementing multi-agency policies and procedures toprotect vulnerable adults from abuse, Department of Health, 2000

Essence of care, Department of Health, 2001 (updated 2003)

Organisational change

Shifting the balance of power within the NHS: securing delivery, Department of Health, 2001

Democratic renewal, 2001

Performance assessment frameworks

Comprehensive performance assessment, Government white paper, July 2002

National standards, local action. Health and social care standards and planning framework2005/2006-2007/2008, Department of Health, 2004


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Documents

Living Well In Later Life (Full Report) - NHS Wales• living well in later life • leading organisations through change In addition to these themes, the local inspections focused