Managers and Medicine

Published: 27/03/2003, Volume II3, No. 5848 Page 37 38 41

Some have claimed the national service framework for older people has been patchy at best. Others describe a steady start for a programme lacking financial investment. Where does the reality lie? Alison Moore reports

Changing the way NHS services are delivered to older people is a massive task, but fundamental to the NHS. The national service framework for older people was published two years ago, covering eight main areas, but how is it progressing?

Older people's services national director Professor Ian Philp is upbeat, while acknowledging the difficulties. He points out that it is a 10-year programme. 'I think April 2003 will see foundations being laid. In the year ahead I will be giving more priority to the clinical standards, having got the fundamentals in place.'

As for this April's milestones (see box 1, overleaf ) he says, 'we will see when we see them'.

However, some commentators feel that, although progress has been made, it has been relatively slow, geographically patchy and has faltered. A Department of Health progress report - Older People's National Service Framework: progress and future challenges - released this week (but seen by HSJ in draft form) is more measured, but admits more work needs to be done in some areas.

Tina Naldrett, chair of the Royal College of Nursing's forum for nurses working with older people, warns that many areas will miss the April milestones.

'Because no money came with this framework, people are struggling to find the resources to meet many of the milestones.'

Jonathan Ellis, health policy officer at Help the Aged, says some key areas of the framework fitted into much wider policy objectives - such as intermediate care to reduce pressure on admissions and delayed discharges. 'There has been a tendency for attention to focus on the big political issues within the framework, sometimes at the expense of equally important parts of the framework, ' he says. 'But that is not to denigrate the huge progress which has been made on delivering a lot of the objectives.

And if we get it right for older people, it will have enormous knock-on effects on everyone.'

Professor Cameron Swift, former president of the British Geriatrics Society, points out that although the clinical standards - fall, stroke and mental health - have a good evidence base and are driving forward improvements, 'the ones that are less evidence-based are presenting more difficulties and there is a risk that they will not deliver'.

So what has been achieved?

Professor Philp is pleased with progress in combating age discrimination. 'Compared with where we were two years ago, there is now a widespread acceptance that it is not appropriate to discriminate, ' he says. 'At a superficial level in policy and in people getting access to services, we have made very good progress. Something like age discrimination is embedded in culture, values and behaviour and it takes longer to turn those things around.'

The DoH review says all but 'a very small number' of NHS organisations have drawn up anti-age discrimination strategies and more operations are being done on older people - for example, in the last two years the number of coronary artery bypasses for people over 85 has risen by 65 per cent. Some national policies are now being examined as they too appear to discriminate, though this may be for clinical reasons.

Another part of the cultural change has been greater involvement of older people in planning services. Age Concern says most of its local groups are involved in some way, for example, developing work on specific standards.

Underlying much of the framework is the concept of person-centred care - with older people treated as individuals and allowed to decide the sort of care they want. Key to this is the single assessment process for both health and social care, introduced in April 2002.

But Janice Robinson, director of health and social care at the King's Fund, points out: 'A lot of places are struggling to make sense of implementing single assessment and person-centred care - some people are finding it hard going.'

Professor Swift says: 'There seems to be no consensus on what the aims of the single assessment are and the nature of its outcome. Assessment requires skills - there is little merit in bureaucratic ritual.'

The DoH report admits that some implementation issues still have to be thrashed out. Though there has been progress on community equipment services, there is more to do - especially to hit the target of 50 per cent more people benefiting from them by 2004, which will need substantial additional investment.

As for the main clinical standards, Professor Philp acknowledges progress has been geographically patchy, but says there are now plenty of good practice examples. The levers are now in place - national taskforce members to champion the different areas, a group of older people to inform the national reference group on impact and 1,300 local older people's champions, now supported by a national development manager.

In intermediate care, there has been measurable progress with more beds than targeted being provided. But there has been concern that the policy of 'letting a thousand flowers bloom' could lead to disjointed services (HSJ, pages 24-26, 31 October 2002).

Professor Philp shares some of this concern as he now talks about 'getting management grip' on intermediate care.

Patients are being given more choice over the care they receive through the expansion of direct payments and, crucially, the rate of delayed discharges among the over 75s has dropped from 13 per cent to 9 per cent in the last two years, the DoH report says.

In stroke, there is concern that the development of stroke units has been very slow despite evidence they improve outcomes (see feature, pages 42-43). The DoH report says that three out of four hospitals now have a specialist stroke unit, but only 36 per cent of people with stroke are benefiting, and organisation of stroke care remains variable.

Falls services are gradually developing and the National Institute for Clinical Excellence is drawing up guidelines on falls prevention by 2004.

Important as these specialist clinical services are, many older people end up in hospital for other reasons and are placed on general wards where even Professor Philp admitted last September standards for elderly people have 'gone backwards' ('Elderly czar bemoans lack of care progress', news, page 6, 19 September 2002).

However, the report is distinctly more upbeat, saying Nightingale wards should be eliminated by April 2004. The DoH claims that 98 per cent of trusts have abolished mixed-sex wards and 93 per cent have provided segregated male and female bathroom and toilet areas. More than 80 per cent of hospitals now have a nurse lead with specific responsibility for older people and three-quarters have specialist multidisciplinary teams.

Health promotion has made 'significant progress' towards its 2004 targets around flu immunisation, giving up smoking and improved management of blood pressure. Professor Philp says he wants to see more joint working on strategies to encourage healthy lifestyles.

Another area of mixed progress is mental health. The Alzheimer's Society has expressed reservations about the lack of detail and standards for people with dementia and says progress may have been slow because the milestones are some years off.

It is also worried that people with dementia do not get access to other services, for example, being specifically excluded from some intermediate care schemes. The DoH report says there has been a three-fold rise in prescribing of anti-dementia drugs between the start of 2001 and September 2002 and that progress is being made, though patchy. However, some areas have a serious shortage of suitable care home places.

Professor Philp says progress in medicines management is slower than he wants. Though not a standard on its own, it still features in milestones. Work encouraging pharmacists, nurses and doctors to address the issue is underway, he says, together with a national collaborative.

In some areas there is well co-ordinated action to drive forward implementation across the board - a London-wide development programme in place for 18 months has included collaborative-type approaches to improving primary care for older people, for example.

1But while progress will continue, there are a number of factors which could slow things down.

One has to be workforce. 'So many of the milestones and targets hinge on having these specialist roles in situ - whether it is a geriatrician, a falls co-ordinator or an intermediate care co-ordinator, ' says Mr Ellis.

The number of consultants has increased to 800 from 680 in 1997, according to the DoH review.

Professor Philp is pushing hard at the bottom rung of the career ladder, arguing care assistants are crucial to the delivery of both health and social care and need training and career advancement possibilities. Properly equipped, they could relieve pressure on people further up, he argues.

The framework did not specify how many extra staff would be needed, nor what extra resources would be needed to deliver this, points out Professor Swift. Nor did it offer a comprehensive vision of the model of geriatric medical services needed. 'To that extent, it is an opportunity lost, ' he says.

An Audit Commission report in October stressed the importance of recruitment and retention of suitably skilled staff.

2But it was moderately optimistic about whole-system working bringing about service improvements for older people. Change is likely to take years, it concluded.

Finance remains a problem - especially for local government, whose partnership is so crucial for much of the framework.

But some strategic health authorities are prioritising spending on older people's services: South Yorkshire SHA, for example, plans to work with primary care trusts to put more money in. 'The ring-fencing of money is something we have identified as a priority, ' says a spokesperson. North East London SHA is also keen to target older people's services through capital development money, which has funded intermediate care developments through PCTs.

Increasingly, the pursestrings lie with PCTs but local delivery plans should have framework targets as one of their main aims, which may hasten progress.

Much depends on the system of older people's champions in each area, meant to spearhead and champion reform. 'It is a good idea' but 'these champions do not have any powers and have only weak accountability', says Ms Robinson.

'It does not feel as strong as what is going on in the cancer collaboratives, for example.'

Age Concern claims there is 'confusion and a lack of clarity' over the roles and responsibilities of champions and has called for it to be evaluated.

3But perhaps the biggest danger is simply the plethora of changing priorities and targets which managers and clinicians have to cope with. How high up their agenda can the framework remain? l Box 1: milestones and targets for the framework, 2003-04

Age discrimination: benchmarking is being developed to demonstrate local improvement.

'People-centred care': by April 2003, hospitals should be surveying users' and carers' experiences and there should be local plans for integrated continence services. By April 2004 these should have been set up, as should single integrated community equipment services. Primary care trusts should be surveying users' and carers' experiences.

Intermediate care: by March 2004, creation of 5,000 new intermediate care beds and 1,700 nonresidential places, with 150,000 people benefiting.

Hospital care: by April 2003, hospitals should have profiled staffs' skills and put education and training in place to ensure appropriate special care.

Stroke: by April 2003, hospitals should be following the Royal College of Physicians' guidelines.

By April 2004, general practices should be identifying people at risk and treating stroke sufferers according to protocols. All hospitals should have specialist stroke services.

Falls: By April 2003, local healthcare providers should have risk management procedures to prevent falls and, by April 2004, plans for an integrated falls service.

Mental health: By April 2004, there should be plans for integrated services. GPs should be using an agreed protocol for patients with depression or dementia.

Health promotion: by April 2003, there should be plans to promote healthy ageing and preventing disease. By April 2004, local health systems should show year-on-year improvements on flu immunisation, giving up smoking and blood pressure management.

Box 2: joint working to benefit older people Older people in Peterborough should start to feel the difference as a raft of changes come into play.

The main driver has been joint working, both between NHS organisations and between the NHS and local government, such as on a taskforce to oversee the national service framework locally.

Older people and their carers are well represented on a forum which informs the taskforce.

Clinical priorities are being addressed: a falls project worker has liaised closely with sheltered homes to put in preventive measures, for example. The falls and stroke co-ordinators work across both the local acute trust and in primary care. A mental health strategy for older people should be agreed by April.

Within Peterborough Hospitals trust, a specialist stroke nurse will ensure better co-ordination between the trust and community. A rapid access service for mini-strokes is being developed, staff training and competencies examined and work is ongoing on indirect age discrimination.

On falls, Rebecca Hardy, trust framework lead, says: 'The milestone is a little bit further off but it is going to require quite a lot of investment. Whether we have an integrated falls service as required by the framework is questionable.

'A lot of the framework implementation is about change management but a lot does require resources. Certain things have been difficult to move ahead on.'

Jane Wheatley, head of services for long-term conditions for the area's two primary care trusts, says they have had to 'scrap around the edges and realign bits of our money'. Some funding has been on a three-year basis and she now wants to see that embedded in the planning process.

She puts their successes partly down to having a unitary local authority making joint working easier, and active older people's champions - both lay people and clinicians. She is confident the PCTs will meet the April milestones.

One champion is Cliff Walker, a 62-year-old non-executive PCT board member, active in the voluntary sector. 'I think we would all like things to be much further on than they are, ' he says. 'We all accept there is a restriction on how far we can go because of staff and funding. But with the resources we have - both human and financial - I think we are as far as we can be expected to be.'


1www. london. nhs. uk

2Audit Commission. Integrated Services for Older People. London, 2002.

3Age Concern and the British Geriatrics Society: reasons for optimism, reasons for concern. 2002.