Primary care groups are facing high expectations that they will improve services for elderly people and their carers.
While there are many examples of innovative services for older people, the current emphasis of health and social services on acute medical emergencies and crisis management has systematically failed vulnerable elderly people and their carers, leaving too many with little choice or control over their lives. There are often few alternatives to institutional care despite the fact that it is not the preferred option for most.
1A strategic approach to the needs of elderly people and their carers would bring considerable benefits to PCGs faced with many competing demands on their budget. For example, improved support for, and awareness of, the needs of informal carers will enable them to continue supporting frail elderly people while maintaining their own health.
The breakdown of informal care is most likely to lead to emergency hospital admission. Investment in rehabilitation will reduce dependency levels of elderly people in the community and in residential care and therefore the demands on primary care teams. Early detection of depression can prevent the cycle of deterioration which otherwise leads to long-term physical and mental health problems.
The challenge for PCGs is how to promote a co-ordinated approach given the often complex and inter-related health and social needs of this client group and the range of organisations involved.
PCGs' plans to improve services for older people should be well informed, but the quality of local information on needs and service availability can be variable.
PCGs will have to balance the desire for high-quality information with the need to get things done. Sources of information could include:
mortality and morbidity data from the local public health department;
population projections to help identify important trends, such as changes in the population of very elderly people;
ad hoc service user surveys or public consultation organised by community health councils, voluntary organisations or the local authority;
practice-based data that can be readily analysed - for example, a manageable sample of primary care health checks for over-75s.
Most PCGs will already know local pressure points in the NHS and this can be a useful way to focus intelligencegathering across organisational boundaries. It makes sense to pool information with social services and housing departments.
The experience of elderly people and their carers
Knowing the overall population needs is only half the picture. Services that professionals think are appropriate and accessible may be unattractive to elderly people or difficult to use. It is important to gauge such assumptions locally. Small-scale surveys, discussions with voluntary organisations or inviting a selection of patients to recount their experiences can yield useful information.
A person's experience of health and social care is profoundly affected by their relationship with those providing services. Care workers who do not have sufficient time to help people undertake personal care tasks are more likely to complete the tasks themselves, depriving the elderly person of opportunities to re-learn basic skills. Patronising behaviour may be based on the automatic assumption that elderly people are less capable mentally, or uninterested in the reasons behind professional decisions.
Unfortunately, negative attitudes and lack of awareness of elderly people's needs are still common, and this is reflected in some people's experience of services. Recent publicity regarding malnutrition in hospital and physical abuse in nursing homes provides extreme examples of de-personalising treatment.
Ageism underlies policies such as age-based referral and treatment criteria.
PCGs need to consider what the prevailing attitudes to elderly people are locally. Are services designed to respond to elderly people as citizens with the same rights, responsibilities and expectations as others?
Are services planned and delivered to reflect the particular needs of elderly people? Do their policies promote equality and mutual respect? Valuable insight can be gained into areas requiring change if service users can recount experiences honestly and openly, ideally to someone perceived as independent.
PCGs are legally required to have strategic plans for involving and communicating with patients and the public, and to provide feedback on the outcome of involvement.
2There is sometimes a mistaken view that elderly people will not want to be bothered with responding to consultation. Statutory organisations may seek representation via existing voluntary organisations, which they perceive as more familiar and therefore comfortable with formal processes. But there is plenty of evidence that elderly people who are actual or potential service users are enthusiastic participants if they are given sufficient background information and treated as equal partners.
Elderly people with the greatest needs may be unable to leave their homes to participate in group events, but one-to-one interviews at home and questionnaires can be used.
Facilitated telephone conferences between small groups of people are also an option and have the advantage of allowing people to clarify their views through debate. If group events are arranged, then accessibility of venues for people with mobility problems or sensory impairments must be considered.
Before embarking on an exercise in consultation, it is important to decide whether the activity is one-off, one of a series of events or requiring some sort of continuous input. Involvement over an extended period of time can allow participants to develop a more detailed understanding of issues and systems and to contribute to evolving plans. Whatever the extent of involvement, the process needs to include providing feedback about the views expressed and their impact on statutory decisions.
PCGs are new players in localities where some joint planning systems will have existed for years. There will usually be an officer-level group with representation from social services, the health authority, housing services, the voluntary sector, the CHC and one or more acute or community trusts. This group may report to a non-executive or councillor forum to ratify strategic decisions, although in some areas the reporting line is directly to constituent agencies.
As major commissioners and providers of care, PCGs need to understand the existing local planning system, decide on how they wish to participate in it and negotiate with the relevant partner organisations. Not only will this enable them to fulfil their statutory duty to make a real contribution to the health improvement programme, it will also allow them to build effective inter-agency relationships and raise their profile.
Getting involved in multi-agency planning groups requires the investment of time and PCG boards should consider whether there is duplication between the PCG's own subgroups and those in existence elsewhere.
The PCG's contribution
If PCGs are integrated into local planning systems they will be signing up to a number of multi-agency plans, including the joint investment plan (relating mainly to elderly people) and the HImP.
They will also have their own primary care investment plan.
There is a risk of being overwhelmed by the number of priorities in different plans. The key step for PCGs is to agree with partner organisations some specific and limited objectives where the PCG can contribute to an overall strategy. For example, a local joint priority might be to reduce emergency admissions of elderly people to hospital. The PCG role in this could be to:
ask primary care teams to provide data on their patients and emergency admissions, for cross-referencing with hospital data;
audit the extent to which primary care teams are aware of at-risk patients in the community;
work with community health services on a primary care contribution to a rapid response team.
Producing separate documents should not be necessary if joint planning documents contain these objectives. The likelihood of success will be greater where plans are not over-ambitious and where one PCG board member is given the lead. The challenge for boards will be to ensure that PCG members are able and willing to participate in meeting the agreed objectives. Some way of monitoring changes will be needed to assess whether the plans have improved outcomes for elderly people.
The King's Fund has launched a two-year initiative to help PCGs develop their role in shaping services for elderly people and carers. Interested PCGs can join and benefit from policy papers and opportunities for learning and sharing experiences.
Key points Primary care groups need to address the needs of elderly people.
Elderly people and their carers should be consulted about services.
Elderly service users can be enthusiastic participants in consultation initiatives.
REFERENCES 1Audit Commission. The Coming of Age - improving care services for older people, 1997.
2Department of Health. Patient and Public Involvement in the New NHS, 1999.