How a leaner integrated approach improved older person services at a reduced cost

The government is encouraging the NHS and local authorities to work more closely together to make efficiencies and ensure patients receive the most appropriate community and home based services to reduce emergency hospital admissions.

The NHS operating framework for 2011-12 created clear incentives to drive this integration by transferring £648m from this year’s primary care trust budgets to local authorities to spend on services that will improve overall health and social care outcomes.

As part of this landscape of integration and cooperation, local authorities are importing quality and efficiency processes from the NHS to help streamline their pathways. Last year, Gateshead Council’s adult social care team, with support from Teal Consulting, applied lean principles to their core assessment process (from the point of referral to a case being closed) and demonstrated the positive effect it had on the health and wellbeing of people receiving their services.

This has helped Gateshead PCT, now part of NHS South of Tyne and Wear, to free up resources. The initiative has been particularly successful targeting waste related to long term conditions, where it aims to reduce the total cost of excess bed days by £1m and emergency admissions (ambulatory care sensitive) by £487,000.

David Hambleton, director of commissioning development for the PCT, says: “Gateshead PCT is very supportive of the work being undertaken by adult social care and recognises the significant benefits the use of lean methodology can bring to users and carers, as well as the staff working across the health and social care sector.

“We look forward to continuing to work with Gateshead Council as it develops its lean programme further.”

Gateshead Council, which delivers services to 191,000 residents, has six corporate priorities including empowering older people and ensuring healthier communities, which aim to support older people and people with disabilities to live independently.

The proportion of over 65s in Gateshead is projected to rise from 33,700 to 42,000 by 2025. Even more dramatic is the expected rise in the population aged 85 and over, increasing to 4,600 by 2015 and to 6,600 by 2020 – a 74 per cent increase from 2008. Furthermore, based on current trends, Gateshead will have a higher proportion of its population over the age of 80 living alone than many other comparable areas (see “Age profile of Gateshead Council social service users” graph, above).

Given its demographics, Gateshead Council was conscious of the need to become more efficient in order to maintain and improve services in the challenging financial times ahead. The council brought in external support and an in-house lean/sigma programme was delivered, initially to a mixed group of staff. The council then applied the techniques to adult services, particularly those for older people with physical needs where a number of issues needed tackling, such as a long, unwieldy and complex assessment process, inappropriate authorisation contributing to budget deficits, clogged up waiting lists, overloaded desktops, staff bogged down dealing with calls and complaints, failed key performance indicators and poor inspection results.

The council’s adult social care service encourages and supports people to live independently in their own homes, as long as it is appropriate to do so. A range of services can be arranged to this end, such as meals, home care and home adaptations, once an initial assessment has been undertaken. The older people’s service carries out around 4,000 such assessments each year and, prior to applying lean, a large proportion of reassessments and reviews on a face-to-face basis.

During the home assessment, a social care professional determines the individual’s needs and risks, then draws up a plan to give them access to appropriate support.

Each person is assigned a named support worker who tries to visit their home at the same time and day each week. Low-level support can be provided for a few hours each week or fortnight, which may involve help with finances and benefit claims, finding out about and joining local community organisations, peer support and befriending, monitoring health and wellbeing, and shopping and other errands.

Before applying lean, the assessment process took around 99 days (see “Time taken to assess service users” graph, above). The team set a target of reducing it to 35 days.

The assessment process involved a number of key stages: acknowledgement of referral, home assessment, financial calculation and start of service. In addition to setting a target time for the whole pathway, the team set targets for each step, including same-day acknowledgements, home assessments within a week, financial calculations within three days and start of service within a week of assessment.

Maximum value

The guiding principle of lean is to maximise customer value while minimising waste, thereby using fewer resources to provide a better service. However, the five steps for implementing lean technique (see “Lean five step process” diagram, above) is not always easy to achieve.

For the older people’s service, the first step involved devoting a day to high-level process mapping, prompting a discussion on appropriate metrics and data collection to support “identifying value”. The team learned that the average length of an assessment was 44 hours (totalling 176,000 per year for all assessments) and the process took an average of 99 days, the longest being 400 days. The team also discussed customer expectations, such as quality, cost and delivery, before considering required outcomes, and then grouping and prioritising improvement ideas.

Teal Consulting then worked with an internal organisational development team to design and deliver a five day rapid process improvement workshop programme, which involved supporting four small groups of service providers who were tasked with progressing themed areas of work.

The approaches they developed had to use existing resources and build upon Care First, improve service quality and maintain safeguarding, while also including preparation for the demographics and personalisation agenda.

The groups made several recommendations that were introduced, including streamlining the allocation process by referring straight to work teams and bypassing managers’ desktops. This meant service users could be contacted within two days, allocated a worker and given a date for an assessment.

Best practice from the physical young people’s disabilities team, who used a simpler more personalised process for respite care, was shared and then applied to the process for older people.

Simple changes

Importantly, the review process for non-complex cases, which was 80 per cent of the workload, was changed from a home visit to a telephone review. A different system was put in place for complex referrals – which became focused on their purpose, outcome and plan – and new operating procedures were produced. Reassessments were also simplified.

Together, these changes provide one simple, streamlined process built around the needs of the service user. Waste had been stripped out, there was an emphasis on improving quality and sustaining change, but risk management, and in particular safeguarding, continued to be 
a priority.

Once these new processes were embedded, the benefits soon materialised. In particular, the number of forms used during the assessment process fell from 52 to 28. Most importantly, where possible all departments used one form to ensure there was consistency in their approach.

The time to complete the whole process was cut from an average of 99 to 34 days and the number of hours needed to undertake each case fell from 44 hours to 7.5 hours, releasing 146,000 hours per annum. From the service user’s perspective, they now had to wait just two days rather than 14 for an acknowledgement and the name of their support worker was provided at this first contact. Reviews also became less intrusive as fewer staff were required to attend.

Review time was also cut from three hours to one and panel meetings became the exception rather than the norm. Inherent to the success of applying lean was devolved decision making, reduced bureaucracy, and more flexibility when responding to problems or issues. A staff survey showed that the changes were well received by staff.

The cost of each assessment was found to have almost halved from £601.31 to £305.49, creating a potential annual saving of approximately £1.18m. Once Teal’s facilitation and support expenses had been taken into account, this equated to a return on investment of 100 to one.

A review of the impact of applying lean within adult services showed that the methodology had been applied to other projects and was becoming a way of life. The significant culture change and rippling effect of transformation was tangible across the service, and beyond.

Furthermore, services appreciated the critical importance of collecting and analysing the right data for informing service analysis and securing improvements for service users. Impact measurements are now in place to ensure changes are effective and contribute to the journey of continuous improvement.

As with any change, the innovations are becoming more adventurous and so now the teams are looking to involve external partners (particularly healthcare) to secure further improvements for service users.