Chapter 2
Summary
2.1 Tayside-wide issues
There were distinctive differences in the way in which the three Tayside health and social work partnerships approached their strategic and operational responsibilities for services for older people, despite there being one health board, NHS Tayside.
There was no over-arching strategic framework in NHS Tayside for older people's services. Although some local variation is to be expected, we consider that there should be greater consistency of approach on key strategic issues. These include the need to shift the balance of care between acute and primary health services and to shift the balance of care from care homes to home-based care.
About two thirds of acute admissions to Ninewells Hospital in Dundee, which serves all of Tayside, were people aged 65 years or over. It was therefore a major and high cost provider of in-patient services for older people in Tayside. The development of multi-disciplinary collaborative services and intermediate care is a key element of national policy as set out in 'Delivering for Health'. 1
Effective services maintain frail older people at home, may often succeed in preventing unscheduled admissions, and can minimise acute stays by promoting early supported discharge with care, rehabilitation and follow up. NHS Tayside needs to address this issue of the balance of care between acute and primary care in a vigorous way, by jointly developing an over-arching and coherent strategy with the three councils.
The three partnerships were fully aware of the need to shift the balance of care from institutional settings such as care homes to providing more home-based care. They had developed plans to do so. However, all the partnerships were finding it difficult to achieve their goals for a number of reasons, of which the most significant was the historical patterns of health delivery, together with the relatively high levels of use of care homes and low levels of intensive home care, as was the case for much of Scotland.
Older people in Tayside were largely positive about the quality of their assessments and the services or treatment they received. They were also largely positive about the way staff from different agencies worked together. However, carers said they were frequently not receiving the support they needed either in relation to their own health needs or from hospital staff when the person for whom they cared was in hospital.
Frontline health and social work staff generally worked together in Tayside in a positive way, with a clear focus on assisting older people to live as independently and safely as possible. This was particularly true of the multi-agency teams in all three partnerships. Multi-agency teams for early supported discharge and prevention of admission provided alternatives to admission and early supported discharge services. These services successfully minimised the acute length of stay and supported older people in their own homes.
Staff in all the Tayside partnerships were struggling to cope with the demands made on them by the incompatibility of health and social work IT systems, particularly in relation to single shared assessments ( SSAs).
The emphasis in current health and social work thinking stresses the importance of early stage, preventative services for older people and the importance of self care, particularly for people with long term conditions. All the Tayside partnerships were aware of the need for services which enable well being and self care, such as case management and rehabilitation, and were beginning to address this.
There were differences about the way that the three partnerships approached the role of home care and social care staff in prompting and/or giving medication, and this was beginning to be addressed. Some services for people with dementia in Tayside exemplified good practice; others were patchy and there were some shortfalls. This was also beginning to be addressed.
2.2 Angus Council and NHS Tayside partnership
The Angus partnership delivered good outcomes for older people through effective collaborative working at all levels. For example, the Manager of the Community Health Partnership and the Director of Social Work and Health jointly demonstrated positive and enabling leadership. The managers from health and social work approached the design and delivery of services in a whole systems way.
Most health, social work and social care frontline staff were committed to working together to ensure that older people and their carers received high quality assessment, care and treatment so that people could live as independently as possible.
There was a wide range of services, and the delivery and management of services, including performance management and continuous improvement, were very positive. There was an up to date joint strategy for older people's services. More work needed to be undertaken on the balance of care in relation to care homes and care at home and the partnership was undertaking this in a variety of ways, for example through a Best Value review and the review of community hospitals.
2.3 Dundee City Council and NHS Tayside partnership
The performance of the Dundee partnership in delivering outcomes for older people through collaborative working between health, social work and social care services was adequate. More attention needs to be given by senior managers from health and social work to jointly implementing a whole systems approach to services and collaborative working. The challenges in delivering on a whole system approach in Dundee are considerable because of the local economic and social pressures.
There was evidence that the partnership had analysed its position and developed some proposals to improve outcomes for older people. However, the pace of implementation was slower than the partnership wanted. There was a need for stronger joint leadership in ensuring collaborative working, particularly in relation to joint commissioning and financing. The existing style of leadership was having a serious impact on the partnership's ability to cope with issues such as the levels of delayed discharges.
Most health, social work and social care frontline staff were committed to working together to ensure that people and their carers could live as independently as possible. Their performance in relation to person centred care in assessment, care management and treatment was good. Staff perceived it as problematic when social work resources were not available to implement the outcome of single shared assessments for individuals, particularly in hospitals, or to provide complex or high cost care packages, which then contributed to the level of delayed discharges.
They were also aware of the impact of Ninewells Hospital, a large teaching hospital in Dundee, which served all of Tayside. It provided an acute service to Tayside and northeast Fife and a community service to Dundee. There was a lack of consistent staffing and the 'boarding out' of patients in temporary places within the hospital which led to difficulties in developing working relationships. There was no other large scale community hospital facility in Dundee.
There was a wide range of services, and the delivery and management of services, including performance management and continuous improvement was adequate. There was no published joint strategy or joint commissioning strategy on older people's services, although considerable work had gone into developing them. More work was being undertaken on improving the balance of care in relation to care homes and care at home.
The partnership recognised it needed to increase the pace of change, and was beginning to do so, for example by the council voting for an additional £1.8 million for care at home services for 2006-07. The partnership needs to consider how it should deliver community health services, particularly in relation to the impact of Ninewells Hospital.
2.4 Perth & Kinross Council and NHS Tayside partnership
The performance of the Perth & Kinross partnership in delivering outcomes for older people through collaborative working between health, social work and social care services was adequate. Senior managers from health and social work were giving significant attention to implementing their vision of the way forward. This clearly involved a whole systems approach to developing services and collaborative work. It was set out in their joint council and health committee paper of July/August 2006.
The strategy for older people's services, dated 2002, needs urgent updating in the light of this paper. Work had begun on this, through the establishment of a new Joint Commissioning Group which was overseeing the development of a range of care group strategies, including one for older people's services. It had a deadline of March 2007 for a draft strategy to be in place.
Most health, social work and social care frontline staff were committed to working together to ensure that people and their carers could live as independently as possible. The partnership's performance in delivering assessment, care and treatment was adequate. However, many staff were uncertain of the way forward since the ending of Care Together (an earlier integration of health and social work services) in 2004. The partnership should involve managers and staff in implementing a joint communication strategy about future developments in services for older people. A draft communication strategy has been developed by the CHP which was intending to consult on how this could be effectively introduced across the partnership services.
There was a wide range of services, and the delivery and management of services, including performance management and continuous improvement, was adequate. However, the partnership had agreed how to improve these areas, for example in implementing a joint performance management framework. More work was being undertaken on improving the balance of care in relation to care homes and care at home. New opportunities for community health services were being considered through the redesign of community hospitals.