OLDER PEOPLE

1. OVERVIEW OF CURRENT AND FORECASTED NEEDS

‘Live Well in Later Life’, Edinburgh’s Joint Commissioning Plan for Older People 2012-22 (p23) sets out the challenges and opportunities presented by demographic change.

The opportunities include people living more healthily for longer. Almost 90% of those aged 65+ are not in receipt of health or care services. Older people also contribute substantially to society. A significant amount of caring for children, adults with disabilities or learning difficulties and older people is provided by people over retirement ages, and many community assets and activities depend on the voluntary contributions of this age group.

There are also challenges. With increasing age there is also an increase in the number of people living with long-term conditions, disabilities and complex needs. Whilst healthy life expectancy (i.e. the length of time people live in a healthy way) has been increasing, overall life expectancy has been increasing faster. This means people are living longer but are less healthy for longer and are likely to require complex health and social care packages for longer periods than in the past.

The number of people over 85 in Edinburgh is expected to almost double by 2032 to 19,294. The number of older people who will require intensive levels of support is expected to increase by 61% over the next 20 year due to demographic factors alone. The number of people living with dementia is projected to increase in line with demographic change. In ten years, time the number of people living with dementia is likely to rise by 22.4% to 8,745 people and in 20 years the number could rise by 61.7% to 11,548 people.

The age profile varies across the city with concentrations of ‘younger’ older people (65-74 years) in the east and west of the city.

There are concentrations of people aged 85+ in the south central area of the city

These patterns are likely to be influenced by factors such as housing and socio-economic factors. For example, in relation to the over 85 populations, these are highest in areas of relative wealth, where people live longer, and also where there is a concentration of care homes for older people.

Levels of need and the ‘balance of care’The prediction of future needs must take account of changes in models of care. A key policy for older people’s services is to ‘shift the balance of care’ from institutional to community based settings. In Edinburgh, the percentage of older people with high level needs who are cared for at home has increased from 14% in 2002 to 35% in 2015. Accordingly the average number of hours of care at home services has risen, reflecting the increased needs of people living in the community. Commensurately,

within care homes people with the lowest dependence has almost halved to 22% of the population, whereas those with the highest needs has increased from 8% to 13%.

Predicting future needs depends on how much further the balance of care is ‘shifted’ to the community, the examples below show how the demand for services varies based on a balance of care of 40% and 50%.

Changes made to any part of the health and social care system have an impact on other areas which also impact on how predictions of future needs are modelled. For example, changes in the criteria in NHS inpatient complex care beds may lead to more of these patients being cared for in care homes or the community.

Needs of particular groupsIt is imperative that all health and social care services are accessible, appropriate and inclusive of and sensitive to the needs of those with protected characteristics and that consideration is given to barriers that can limit access for particular groups.

Within Edinburgh LGBT Age project has produced a film and other materials that raise awareness of the challenges that LGBT older people can face when accessing health and social care services. The project has provided training and materials for services to help them to become more inclusive, including an audit tool and ‘ten top tips’ document

A number of specialist day services for older people from minority ethnic communities are funded by the City of Edinburgh Council. Work is underway to implement the recommendations from a consultation undertaken in 2013 around a future model for these services.

2. PROFILE OF ACTIVITY

‘Live Well in Later Life’, Edinburgh’s Joint Commissioning Plan for Older People 2012-22 (p14) provides an overview of the range of services provided for older people in Edinburgh, which include:

Key areas of service include:

Preventative servicesThe voluntary sector are important providers of low level, ‘preventative’ services and support. NHS Lothian and the City of Edinburgh Council give £4.2 m per year through grants to voluntary sector organisations providing preventative services. EVOC recently identified over 1,700 activities taking place for older people every week from walking groups to singing clubs, from dominos to Tai Chi. LOOP (Local Opportunities for Older People) networks have been established in 4 sectors of the city to help link people to organisations providing these activities for older people.

Day ServicesDay service provision includes registered day centre services (1621 places each week), registered non-centre based one to one services, and day clubs and lunch clubs.

The City of Edinburgh Council’s spends £4.7 million per annum on day services Of this sum, £1.2 million (26%) is allocated to Council day services and £3.5 million (74%) to voluntary sector day services.

HomecareHomecare is a core service supporting people to remain at home. Almost 40,000 hours are provided a week. 25% in house and 75% external. 1,334 people receive an in-house service and 2003 receive an external service.

Care Homes There are 62 care homes in Edinburgh of which 11 are owned and run by the City of Edinburgh Council and 51 are private. The private care homes are owned by 32 different providers.

There are 2,831 care home beds within the city excluding respite and step down beds, of these 565 (20%) are run by the City of Edinburgh and 2266 (80%) are owned by independent providers (voluntary and private sector)1.

Primary and Community Health CareEdinburgh Community Health Partnership provides primary and community health care services including GPs, district nurses, health visitors, practice nurses, occupational therapists, podiatrists, pharmacists, dentists, opticians and dieticians.

Hospital Based ServicesHospital based services within Edinburgh include acute hospitals (the Royal Infirmary of Edinburgh and the Western General Hospital), rehabilitation and specialist non-acute sites (Astley Ainslie Hospital, Royal Victoria Building, on the Western General Hospital site, Royal Victoria Hospital, Liberton Hospital), psychiatric and mental health services (Royal Edinburgh Hospital), Inpatient Complex Care Corstorphine Hospital, Ellen’s Glen, Ferryfield House and Findlay House), Day hospitals for older people and other specialist services provided from the Princess Alexandra Eye Pavilion, Chalmers Sexual Health Centre, Lauriston Building etc.Whilst specialist services for older people are available (Medicine of the Elderly and Psychiatry of Old Age services), the majority of people within all hospital wards are aged over 65 (approx 70%).

1 At November 2014

Number of older people in hospital/ care homes/ at home

Hospital2 Care homes3 Receiving health and social care support at home4

Number of people aged 65+

1139 2625 3650

% of total population (65+)5

1.6% 3.6% 5.1%

Number of people aged 85+

700 1567 1712

% of total population (85+)

6.8% 15.3% 16.7%

Balance of resourcesThe diagram below shows how the totality of resources for older people’s services were allocated in 2012.

Total financial resources for older people’s care and support by service categories (2012/13)

3. EXISTING PLANNING GROUPS

Joint Older People’s Management Group - monthly meeting of Senior Managers from CEC, NHSL, voluntary sector, independent sector and user representatives. This group has the whole systems overview with the aim of improving the delivery and co-ordination of care for older people across Health and Social Care

2 number in-bed midnight 31/12/20143 number in long term placement as at 31 Dec 144 as at Dec 145 National Records of Scotland. (2013). Mid-2013 Population Estimates Scotland.

Edinburgh Dementia Delivery Group – bi-monthly meeting of managers and representatives from H&SC, NHS Lothian, voluntary sector and independent sector, with a focus on services and support for people with dementia and their carers.

Sense of Belonging Delivery Group – A meeting of Senior Managers from H&SC and NHS Lothian to focus on older people and mental health.

Edinburgh Unscheduled Care Board – weekly meeting involving Chief Executives, Directors and Senior Managers from NHS Lothian and H&SC with a focus on unscheduled care/ delayed discharge pressures. Older people are a priority as they form a large proportion of the people subject to unscheduled care and delayed discharge.

Edinburgh Frail Elderly Intermediate Care Strategic Group – recently revised group to oversee the strategic development of intermediate care services in Edinburgh. Membership includes leads from NHSL secondary, primary and community care services and H&SC services for older people.

Checkpoint Group for Older People’s services – role in considering equalities issues, advises on policy and strategy development. Membership includes officers from H&SC, NHSL, voluntary sector and independent sector, older people and representatives from equality groups.

4. EXISTING STRATEGIC PLANS

‘Live Well in Later Life’, Edinburgh’s Joint Commissioning Plan for Older People 2012-22. The principles of Live Well in Later Life are robust regarding shifting the balance of care to the community, but the detailed capacity planning work to deliver these aims continue to be developed.

The older people’s accommodation strategy is an integral part of ‘Live Well in Later Life’. The detailed delivery model is regularly reviewed and developed in line with local development opportunities.

A Sense of Belonging, a joint strategy to improve the mental health and well-being of the population of Lothian (2011 - 2016) sets out how partners will work together to improve mental health and wellbeing for people of all ages and ensure that the services delivered have an ethos of recovery embedded within them. All priorities in A Sense of Belonging are also applicable to older people.

Edinburgh Dementia Implementation Plan 2011-12 was developed to set out how the priorities of the National and Lothian Dementia Plans would be implemented in Edinburgh. Work is underway to review the progress made and develop the local plan for the future.

Care at Home Commissioning Plan 2015 – this plan has been developed as part of the commissioning process for care at home services, to inform the procurement process planned for later in 2015.

The Commissioning Plan for Social Care Day Services for Older People 2012-17 sets out the commissioning approach for day services, based on the results of a significant consultation in 2012. The plan included a recommendation for developing a locality approach to day services and wider preventative opportunities for older people, which subsequently became ‘LOOPs’ (Local Opportunities for Older People).

5. CURRENT PRIORITIES

Unscheduled care – reducing the number of people delayed in hospital and preventing avoidable admissions to hospital is a key priority for the partnership. This is a key driver for a range of other priorities, with the aim of removing blockages and improving the ‘flow’ of people moving between hospital, care homes and the community. The overall aim is to ensure that people receive the care that they need at the right time and in a setting appropriate to their needs.

Care at Home services – this is a core service which supports around 3,300 people to live at home. The demand for care at home services has increased at approx 15% per annum in recent years, which is outstripping the current available supply, leading to significant unmet need of around 5,000 hours per week and unsustainable budget pressures. A Care at Home Commissioning Plan has been developed which sets out the challenges faced, along with proposed actions to address some of these challenges. A new contract will be implemented towards the end of 2015.

Accommodation Strategy – in addition to a lack of capacity in care at home services, another reason for people being delayed in hospital is the lack of a suitable care home or community setting for them to return to if they are unable to manage at home. The accommodation strategy includes long and short term accommodation options to prevent people being admitted to hospital and enabling them to be discharged when they no longer require hospital care.

Preventing hospital admission – there are a range of work streams underway which aim to support the increasing numbers of frail older people with increasing health care needs in the community, preventing avoidable hospital admissions. This requires robust primary and community care services that are able to identify people at risk at an earlier stage and can work together to support the person at home or in a care home.

Preventative services – investment in preventative services was a key focus for the national Reshaping Care for Older People strategy, informed by the Christie Commission report on the future delivery of public services. The Change Fund for Older People provided significant additional investment for preventative services for

older people which needs to be considered as this funding ends and partnerships move towards integration. Preventative priorities include reducing social isolation, falls prevention,self management of long term conditions, technology enabled care and promoting healthy lifestyles.

6. FUTURE USE OF RESOURCES

Addressing the priorities identified above within the very difficult financial context will be a key challenge for the Health and Social Care Partnership.

In line with the national Reshaping Care strategy, ‘Live Well in Later Life’ is predicated on a shift in the balance of investment to support the shift in the balance of care. With a limited financial envelope, this will require disinvestment in services in order to shift the resource to new models of care and agreed priorities.

Workforce planning and development is another key challenge for delivering health and social care services. The recruitment and retention of staff is a challenge for all service providers and is a particular issue in Edinburgh due to relatively high levels of employment.

Moving to locality workingMany older people’s services already work on a locality basis due to access to these services being through sector teams. Organisations and teams supporting older people already have well established links at a local level and developments such as the LOOPs initiative aim to strengthen these networks. Mapping work and census data analysis is being used to help understanding variations in need, demand and provision across the city. The move to new locality boundaries will undoubtedly be challenging, but will result in coterminous boundaries which will provide the opportunity for improved partnership working in the longer term. Another challenge of a locality focus will be to balance how we meet varying needs of local communities whilst also providing equitable services for those that need them.

Chapter authors: Caroline Clark, Planning and Commissioning Manager (Older People) and Jamie Megaw, Strategic Programme Manager for Older People, NHS Lothian.