Senior and heard

Published: 12/02/2004, Volume II4, No. Page 5892 32 33

A programme to address the social as well as medical needs of old people has given a shot in the arm to London boroughs, as national service framework targets loom. Mary-Louise Harding reports

Like many parts of the country, not all London boroughs will be able to tick the box marked 'completed' next to the April target for implementing the 'single assessment process' in the older people's national service framework .

But thanks to the efforts of the London older people's service development programme (which used the SAP target as a hook), some are arguably far closer to the target than would have seemed possible two years ago.

A runner-up in the highly contested reducing health inequalities category of the 2003 HSJ Awards, the programme covers 25 borough-based projects. Each has a dedicated lead manager and multidisciplinary steering group.

The projects targeted high-resource users - people aged over 75 who were frequently ending up on acute wards - to determine if improved and integrated health and social care services could nip potential acute demand in the bud. The projects found that if an older person had improved education about their condition and how and when to use their medication, helping to lower anxiety, and a telephone number of a specialist team to contact in the community, they are less likely to have an exacerbation of their illness and subsequently reduced need for acute services.

Funded by money from the budget of former London director for primary care (now national director) David Colin-Thomé, the 12 'early adopter' organisations selected for the two-year phase-one development received£75,000 each, while the remaining 13 received half that sum to develop over one year halfway into the project.

A care co-ordination service (CCS) for Brent in north-west London was part of the first phase. 'If you have one person [co-ordinating] the different services attending on one person, with a single goal, then It is easier for them to work together to achieve it, ' says former project lead Ruth Adam.

'Maybe before, you had a district nurse dealing with continence, a physio dealing with muscle tone, and social services providing food - all quite disparate.

Now, they are talking to one another and have a combined patient outcome goal to get that person fit to, say, go on holiday. It is very motivational for everyone involved, including the patient.'

Brent CCS brought together partners spanning the primary care trust, social services, the acute trust, the voluntary sector and two GP 'pilot' practices, and appointed four part-time staff, staggered over a sixmonth pilot period. The staff are split between social services or Willesden Community Hospital to 'case manage' 29 vulnerable older people through the system.

The evidence that this approach has worked - at least in terms of reducing dependence on health services - is strong. In the six-month pilot phase, hospital admissions across the group dropped by almost half (47 per cent) compared to the previous six months, while accident and emergency attendance dropped by 53 per cent, and GP home visits by 65 per cent.

The project was in fact deemed to be so successful that the CCS went on to clinch funding to expand its services across Brent, and four care co-ordinators began work to this end at the start of the year.

The most valuable lesson learned by all projects is the importance of 'knowing who is in your system', says former programme director (now service improvement adviser to all five London SHAs) Val Jones.

'We have four-hour wait targets at A&E, but what we do not do systematically is know who's turning up frequently. There are many people in the system, particularly with not so well-managed chronic illnesses who keep pitching up at A&E. But nobody has the responsibility or the authority to note down that information.

'Based on the evidence gathered from our programme, those people can be managed very effectively to tackle this, so not only do you get better outcomes for those people, you reduce demand, thereby freeing up capacity for people who do need urgent and acute care. This, of course, helps to meet the four-hour target.'

Not all of the projects have been successful in securing funding following the pilot, but Ms Jones argues that the skills, learning and knowledge will remain with the staff across agencies.And according to the programme analysis, a typical London borough can save£11,903 per patient, per year, based on the cost of a generic bed day.

The programme certainly speaks the favoured dialect ofa 'fully engaged' future, and goes some way towards focusing minds on standard eight of the NSF, which looks to improve general well-being and opportunities for the ever-growing elderly ranks.

'We looked at the wider determinants of health, ' says Ms Jones. 'It wasn't just about looking at the absence of disease, it was looking at the whole person - whether their income was adequate, whether they were able to get out and socialise, and if they were not how their social needs were met.

'This is a whole range of things beyond the clinical presenting problem, because It is well known that if you increase someone's level of income and give them a greater sense of control over their own lives, it actually improves their health status.'

An evaluation of the programme by the Institute for Applied Health and Social Policy warned that sustainability of the project relied in part on ensuring the 'focus on taking small steps to achieve change is not lost'. It noted that some of the projects were already identifying significant changes in terms of 'spreading' the pilot across the borough, and were moving very quickly towards 'giant leaps.'

However, it concludes that 'it is a measure of this programme's success that so much of it is now embedded within the work of local projects'.

Smart moves from SHIFT

How home-based technologies reduce institutional care Project SHIFT (substitution of hospital and other institutional-focused technology) - funded by the NHS Estates research and development programme - looked at a new approach to home care for older people.

It asked if existing home-based technologies were fully used, could demand for institutional care be reduced?

The review covered areas of dysfunction that affect older people suffering from six major disabling conditions: ischaemic heart disease;

cerebrovascular disease;

lung, trachea and bronchus cancers;

unipolar major disorders;

dementia and other degenerative and hereditary central nervous system disorders; and osteoarthritis.

Three 'bundles' of technology were identified: the first is applicable to all older people; the second to those exhibiting frailties common to all the disabling conditions; and the third to those with dysfunctions specific to each condition. The bundles were designed to be cumulative - so bundle two was designed to be additional to bundle one and bundle three additional to bundle two.

The focus of bundle one (no dysfunction) was on a comprehensive general assessment in a GP practice by a multidisciplinary team. Bundle two includes 'smart' technologies, most of which maintain passive monitoring and can be easily installed in the person's own home. Bundle-three technologies are more complex and specialised, often used in purpose-built 'smart homes'.

Own-home residents who are waiting for a nursing or care home place, and people recently admitted to a care bed, were identified as being the most likely to benefit from introduction of technology.

Table one shows the numbers in the sample for whom home care with bundle provision could be a serious alternative to residential care.

Savings occur almost across the board, with the major exception of those with the highest care requirements, where the costs of technology-assisted home care are higher in both the initial and subsequent years.

Professor Morton Warner is director, Welsh Institute for Health and Social Care, and Professor David Cohen is health economist, Glamorgan University.

Key points

A service development programme is helping London boroughs meet national service framework for older people deadlines.

The scheme identifies older people at risk and co-ordinates work across careteam boundaries.

Hospital admissions among the elderly people the project helped dropped by 47 per cent.