Research has suggested that much of the ambitious investment proposed for winter pressures money did not take place, and the investment that was made yielded only limited extra services.
1There is evidence that the most successful projects involved a whole-systems perspective which demands a radical attitude to organisational boundaries.
2 Eligibility criteria The rapid-response team created in South Ayrshire in 1998 embodied a whole-systems viewpoint. It succeeded in preventing hospital admissions and achieving the earliest possible discharge over the winter period.
The team is a partnership between South Ayrshire council, Ayrshire and Arran health board, Ayrshire and Arran Acute Hospitals trust, Ayrshire and Arran Primary Care trust and the Scottish Ambulance Service. It consists of a social worker, occupational therapist, physiotherapist, bed manager (plus two assistants), district nurse, occupational therapy technician and a generic therapy helper.
From December 1998 it used eligibility criteria agreed between the partner agencies. These dictated that those referred should:
be capable of being cared for at home safely with a multidisciplinary integrated package of care;
have foreseeable care needs with a finite duration, ideally for up to 14 days;
not have long-term chronic or deteriorating conditions which would require indefinite care.
Referrals can come from ward nursing stations, accident and emergency departments, outpatients, day surgery, GPs and primary healthcare teams. A key feature of the process is the multidisciplinary assessment undertaken by the occupational therapist, physiotherapist, social worker and district nurse. In some circumstances, staff from one discipline undertake the whole assessment, which is accepted by the other disciplines.
At the care-planning stage, services (including the number of care hours) are designed to fit assessed need.
Care is then commissioned from home care providers. The team monitors the patient in the community and decides when the care package can be withdrawn, handing over, as appropriate, to the standard community care team, domiciliary therapy services or day hospital.
Climate of excellence We believe factors in the venture's success were:
a 'climate of excellence' in the host South Ayrshire Acute trust and the other partners;
senior social work managers' realisation that they had natural linkages with acute hospital services, as well as primary care - their participation in a joint health and social services management development programme may have fostered this;
the unwillingness of team members to let down their professions and a realisation that they were flag-carriers for a new initiative;
a loose-tight approach adopted by the project steering group which set clear goals but trusted the team to achieve these without constant supervision.
Follow-up In the summer of 1999, the agencies provided consultancy support to help the team build on the success of the winter period and to prepare for 1999-2000. This consisted of five team-learning days, focusing on leadership, decision making and team meetings, performance management, internal working processes, accountability and publicity.
A recent evaluation of a similar initiative concluded that team-working was crucial to success and allowed members to share and enhance their skills, as well as developing a mutual sense of trust and a confidence that the patients' needs were being met.
It cannot be assumed that the same quality of service would result if the same mix of skills was provided, but with staff located in professional groupings.
4The experience of the South Ayrshire team bears this out.
The team's achievements 118 early discharges from acute hospital beds between January and March 1999;
70 admissions to acute hospital beds prevented in the same period;
about 718 extra acute bed days made available;
a low (3 per cent) readmission rate.
1 Beddow T. Frozen Assets. HSJ 1999; 109 (5671): 24-25.
2 Scrivens E, Cropper S, Beech R. Making Winter Monies Work: a review of locally used methods for selecting and evaluating supply-side interventions . Centre for health planning and management, Keele University, 1999.
3 Edmonstone J, Havergal M. The third way: a new approach to management education in health care. Health Manpower Management 1998; 24 (1): 33-37.
4 Beech R. Research Evaluation Of Walsall Health Authority's Waiting List/Whole Systems Initiatives . Centre for health planning and management, Keele University, 1999.
John Edmonstone is a programme associate, centre for the development of nursing policy and practice, Leeds University. Maggie Havergal is director, Havergal Associates, Edinburgh. Jim Crombie is general manager (surgery), Ayrshire and Arran Acute Hospitals trust. Ian Kerr is assistant principal officer (community care), South Ayrshire council. Liz Moore is community services manager, Ayrshire and Arran Primary Care trust.