Published: 24/04/2003, Volume II3, No. 5825 Page 22 23 24
A scheme that set out to improve the lives of older people became a successful example of joint working between health and social care, as Vari Drennan and colleagues explain
The national service framework for older people aims to promote independence in later life and a healthy, active old age through preventive strategies and partnerships between health and social care services.
1Across the country, primary care trusts are setting up partnership projects to promote health in older people using case-finding strategies.
In January 2001, a partnership group in the London borough of Camden established the WellBeing team, staffed by community nurses and social welfare officers. The original partnership group included North and South Camden primary care groups, Camden social services, the health authority, the community health services trust and Camden Age Concern. The team consisted of three community nurses, three welfare officers and a part-time administrator. The nurses and welfare officers worked in pairs.
The Well-Being project, due to run until July this year, aims to reduce social isolation, enable mainstream services to focus more effectively and to foster self-help for older people. From the start, the team worked with GPs to identify people over 75 who had not been in contact with the practice over the past year, who lived alone, or about whom the practice had concerns.
These people were then offered a joint health and social welfare assessment service in their own homes. The team followed this assessment with short-term activities of information, support and referral as necessary. A comparative group of people aged over 75 from the practice list was also offered the service.
Three months later, the team reviewed everyone that received the service. An evaluation group undertook interviews with team members, older people receiving services, GPs and individuals from the project leadership. Data on unmet needs, referrals made and benefits obtained were collected by the Well-Being team and analysed by the evaluation group.
There was enormous commitment and enthusiasm from all the partner organisations. But most of the managers and the team characterised the first six months as confusing and frustrating.
There was real tension in the partnership about whether this was a case-finding project or a more global outreach service.
2The project partners had different aspirations and cultural inclinations for the project that were not easily reconciled.
The partnership arrangements, while very inclusive, left unclear who held decision-making authority. The diffuse roles, responsibilities and split finances meant initial progress was slow.
Initially, the scheme was managed by a multiagency group and then by a designated project manager in the PCGs/PCT. Key lessons that project partnership members identified for all multiagency and multi-organisation projects were:
The importance of clear terms of reference and membership criteria for all partnership project steering and management groups.
Unification of partnership finance into one budgetary source.
Identification of a senior project manager with sufficient dedicated time.
An agreed project development and operational plan before staff are employed.
Explicitly locating the project in the whole system of services for older people.
The team worked with 18 general practices across the borough. Other practices were approached but declined, one because the GPs viewed a short-term project as inappropriate for providing continuity for their older patients.
The Well-Being team experienced an ambiguous response from GPs who, although welcoming additional resources for their patients, were concerned about patient confidentiality with shortterm project workers (some not employed by the NHS) and a mismatch between the centrally defined work of the Well-Being team and practices' activities and priorities.
The Well-Being team sent letters offering its service to 1,271 people. The patient lists obtained from some general practices proved to have significant numbers (47 per cent) who were no longer at that address. Thirteen per cent of people offered the service declined it. GPs reported that some people considered the project intrusive and unacceptable.
The team members emphasised that, as an unrequested outreach service, they had to spend time establishing relationships with people. In many instances, it took more than one visit to complete the assessment process. The average time for a first visit was 69 minutes. The Well-Being team abandoned the use of palm-top computers in the person's home as it detracted from the communication process with the older person.
Older people reported to the evaluation team that the presence of two people in their home was not a problem as they knew in advance that two people were coming. The team members pointed out that they were also aware of times when it had been uncomfortable and inappropriate.
Team members and some project managers questioned the value of two team members undertaking the assessment together. The nurses believed that they could undertake all aspects of the assessment alone and then refer appropriately. The social welfare officers challenged this view but were clear there were technical aspects of this assessment that they would not have the appropriate knowledge to undertake.
In all, 320 people gave their consent to their information being used in the evaluation. Ninetyfour people (29 per cent) had unmet needs identified. The most frequently reported unmet needs were physical health, mobility, poor memory, maintaining a balanced diet and looking after the home.
There were a higher proportion of people with at least one unmet need in the group selected by the general practices (33.9 per cent) than in the comparative group (19.2 per cent).
Twenty-three people (7 per cent of 247 people for whom data was available) had geriatric depression scale GDS-15 scores indicating clinical depression.
Forty-four people (20 per cent of 264 people for whom data was available) had abbreviated mental test scores indicating problems with cognition, but only nine people (3 per cent) were found to be socially isolated, confirming the findings of previous local projects and studies.
The community nurses and welfare officer asked the older person to identify a personal goal.Many people were unable to suggest one, and those who did described goals that ranged from the global, as in 'world peace', to the very personal, as in 'to be buried beside spouse in another country'. The most frequently reported personal goals of older people were to move home, to leave the house more often and to have improved health.
Using their knowledge of benefits and local amenities, the team was at least able to refer 315 of the 320 people in the evaluation to other services and sources of finance. There was no significant difference in the number of referrals made on behalf of people selected by the GPs to the comparative group.
The service most frequently referred to was the GP, followed by the occupational therapy services, the housing department and social services. GP referrals mainly involved people with multiple problems, hearing difficulties or raised blood pressure.
The GPs were clear that referrals to them were appropriate, welcome and had not increased the workload of the practice.
Thirty-eight per cent of people had help from the team in applying for finance. The total amount of money raised on behalf of older people was£145,522. The largest source was£95,370 in attendance allowance for 39 people. The Well-Being team also met reluctance and refusal from older people to pursue sources of financial assistance.
A global picture of health and well-being from the older person's perspective was gained at the first assessment and at the follow-up interview using the SF-8 survey, which measures a person's own perception of their health and wellbeing.
4There were observed and statistical improvements in physical functioning and general health dimensions of those with three or more referrals made on their behalf by the team.
There were no significant differences on any dimension between the GP-selected and comparative group of people.
All the older people interviewed by the evaluation team were very positive about the WellBeing team. Some considered the service as acceptable because the GP had offered it. The older people were not homogeneous in their needs, knowledge or experience.
Those people who were referred to a number of services or were helped to apply for finance pointed to the difference the service had made to their lives. Older people who met the team and then had little subsequent involvement saw the value for others but not themselves.
Some people told evaluators they viewed the WellBeing team as a point of contact if they needed help in the future. They placed value on a service that would continue to exist.
The pro-active outreach service was acceptable to many older people - however, not to all as a minority refused the service. There was a clear expectation from many older people that the value of such a service was in its continued existence, to be called on in time of difficulty. GPs perceived the additional service for older people as very acceptable but likewise questioned the value of a short-term project with centrally determined methods.
The GPs were effective in identifying people who were more likely to have an unmet need. There was no difference in volume of referrals to other services between the group identified by GPs and the comparator group.
The explanation for this probably lies in the WellBeing team's knowledge of local services and sources of finance, as well as screening for hearing problems and hypertension.
The team was effective in making a difference to the lives of those older people they introduced to more than three services, as measured with the SF-8 scale. They made a financial difference to the lives of over one-third of those people they met.
The method of contacting older people through general practice lists was inefficient. It is recognised that such lists are inaccurate compared to resident populations across the UK and particularly in inner London.
5Fourteen per cent of the people who received the first assessment from the Well-Being team were not at the same address three months later.Although the literature suggests postal screening from general practice can be very effective in identifying older people who can benefit from services, it too becomes inefficient when there is a substantial time lag in changing general practice records.
This project has provided valuable learning for the implementation of a number of the targets in the framework for older people, including single assessment, the prevention of falls, and review of medication.
The challenge is to take those elements that achieved demonstrable outcomes for older people - such as the outreach and the promotion of eligibility - and provide them in ways that increase the acceptability to older people and efficiency in resource utilisation.
Most specifically, commissioners must note that identifying older people with multiple unmet needs (also known as case finding) through inner city general practice registration remains problematic.
The mobility of this age group is undocumented, but this project indicates that it is considerable.
Joint working across different organisations is, and will continue to be, complex and challenging.
This case study provides a number of lessons for future developments.
1Department of Health.
National service framework for older people. Stationery Office, 2001.
2Department of Health. The single assessment process: assessment tools and scales. Section 19.
www. doh. gov. uk/scg/sap/to olsandscales/index. htm
3London Borough of Camden.Vulnerable older people project. Residents of Concern Project Report.
London Borough of Camden, 1998.
4Ware Jet al. A manual for users of the SF-8. Lincoln RI: QualityMetric Incorporated, 2001.
5Select Committee on Public Accounts. Fifth report NHS (England) summarised accounts 1997-98 paragraph 48. UK Parliament, 1998.
A scheme offering joint health and social care assessments to people aged over 75 in inner London identified more than a quarter in need of services.
The older people were accessed via general practice, but this proved an inefficient way of identifying the target population. In some practices, almost half of those contacted were no longer at the same address.
The assessments, conducted by a community nurse and social welfare officer, often involved two visits.
The mobility of the elderly population needs to be taken into account when planning joint assessments.
Organisations involved had different aspirations for the scheme and management proved problematic.
Vari Drennan is senior lecturer in primary care; Steve Iliffe is reader in general practice; Deborah Haworth is research fellow; Sharon See Tai is senior research fellow in quantitative methods and analysis; Penny Lenihan is lecturer in primary care and old age; Toity Deave is research fellow, primary care nursing research unit, department of primary care and population sciences, Royal Free and University College Medical School, London.