CHAPTER 7
Dundee City Council and NHS Tayside partnership
7.1 Person centred care
There were well established processes for assessment, care management and treatment in social work and community health services. The experience of people receiving services was taken into account when delivering or developing services. There was a strong ethos in Dundee of enabling well being and self care and the council prided itself on the availability of lower level supportive services. Performance in this area was evaluated as good.
7.1.1 Assessment and care management
Assessment
There was a well established inter-agency single shared assessment ( SSA) process which fully considered individuals' needs and preferences. Dundee health and social work staff were particularly concerned about the difficulties of sharing SSA information with other agencies and said they had to fax copies to each other which took a considerable length of time. Like some other councils, Dundee's intention was to incorporate the IoRN, a national tool to measure levels of dependency and assist in long range planning of services, into the SSA when IT systems were developed.
The full SSA form was not generally used within hospital records. It was used by community health staff when making referrals. It was partially used by the council occupational therapy ( OT) service and was well used by home care staff. It included health and social information. Rehabilitation plans were found in just over a third of files - in very few council files but in the majority of NHS files. The case file reading found that community care needs were recorded in three quarters of council files, and also in the majority of NHS files.
Dundee recognised the importance of carers assessments and had developed a form that carers could complete themselves if desired. Evidence from the case files and carers focus group showed that it was not well known about or widely used. The low completion rate was being addressed by the carers strategy group and the Princess Royal Trust centre. However, evidence from case files and the survey showed that about half of the carers were having their needs identified and addressed. This suggests good practice in that although staff were not widely using the form, they were discussing carers needs with them.
Some service users have very particular needs. The SSA required details of 'ethnic group and cultural background' and included a sheet for relevant details. Information about the needs of minority groups was also obtained from representative groups. The ' NHS Tayside Race Equality Scheme Action Plan, 2005 - 2008' was a positive document. There were some services such as the Dundee City Council interpretation and translation service and the Chinese lunch club, but culturally sensitive services for ethnic minorities generally appeared to be limited.
Research on minority ethnic groups suggests that they want the same services as British older people but they want them to be culturally sensitive. The work on setting up an acceptable meals service in Dundee demonstrated this. There were no users from minority ethnic groups in the council's day centre for older people and it might have been possible to widen access to include them, with more flexible opening hours if necessary, as was done with Alzheimer Scotland. The department was working with a multicultural working group to develop a new multicultural day service.
Care management and treatment
Dundee social work staff were committed to the care management process to enable people to live independently. The analysis of case files showed that over two thirds of files contained care plans (although these were very often home care service plans), and over two thirds had evidence of reviews. Home care staff drew up exemplary care plans for their service which were then kept in folders in the houses of service users and were available for other staff. In addition, many services, such as the day centre, the day hospitals and residential homes, had their own documentation.
Involvement of service users was strong - all documentation required the signature of the user, and users were involved in care planning meetings. Advocacy was available and a review of advocacy services was almost complete. Direct Payments were available and of the 33 people receiving them, nine were older people. Case file analysis showed evidence that the views of individuals were taken into account in nearly all cases. Care home placements and housing with care usually had to be allocated on the basis of need or availability rather expressed preference. The limited availability meant that first choice was not always a possibility.
An interesting feature of Dundee was that people retained their GP and therefore also the community nurses when they moved house. This was usually an advantage for the older person, if not for staff from other agencies who worked on a locality basis and had to relate to many different GPs and community nurses. Consistency in personnel was identified as a key issue by the Tayside Managed Care Network for Dementia, and it was helpful that GPs could maintain contact.
Although clearly there were problems with hospital discharges, practical arrangements made by frontline staff seemed to work satisfactorily, for example with most equipment arriving when required. This seemed to be a result of a really strong motivation of both staff in the hospital and staff in the community who said they wanted to 'get it right'. Thus, for example, when a commode was not ready for a recently discharged woman, the social care worker got one for her from the store.
Good practice - Dundee partnership number 1
A married couple moved to Rockwell Housing, a new partnership arrangement between a housing association and the Social Work Department, with a social care team on site. The facility included a number of flats for two people as well as one person flats and this enabled the couple to remain together. The husband was able to continue caring for his wife who had significant personal care needs, with additional support from the care team on site.
Information sharing between agencies to ensure seamless care was underpinned by several policies and protocols such as the NHS Code of Practice and consent forms as part of the SSA process.
There was an impressive range of developments to improve care and treatment within the last 12-18 months, such as the redesign of the Intensive Care at Home Service, the Lochleven intermediate care facility, the Chinese lunch club, Rockwell housing with care and the planned joint equipment store.
7.1.2 Experience of people and carers when receiving services
This section looks at how the experience of people receiving services was used in service delivery and development. The Dundee partnership worked hard to obtain feedback from users and carers, for example a survey of home care staff and service users had just been completed. A telephone survey was ongoing in relation to the First Contact Service, which provided the first point of contact with council services. There had been a patients' satisfaction survey of the intensive care at home and rapid response services and an evaluation of the Parkinson's clinic group therapy.
Dundee had also just completed a carers survey which provided useful views on respite. These had been fed into the ongoing development of a carers strategy and the review of respite. Action had been taken to increase the care at home respite service to about 600 hours service per week. Action was also being taken to improve services such as the change to SSA forms to include the views of carers. However, our survey of carers showed that only about half of carers for older people in Dundee felt valued and listened to by social work staff.
There was provision of advocacy, for example through Age Concern, Alzheimer Scotland and DIAS which has a specific remit to cater for people with dementia and mental health problems. Managers recognised that advocates give a mixed feedback to them about services and that more advocates were needed. They were reviewing advocacy services and would incorporate views of individuals, carers and staff in this.
7.1.3 Enabling well being and self care
There was a strong ethos in Dundee of enabling well being and self care. Dundee prided itself on the availability of lower level supportive services such as the shopping service, the handyman service, the domiciliary meals service, the community alarm service and the home care service. All these services assisted people to remain independent and we recognise the value of these services. There must, for people with dementia, be issues about all these services being delivered separately. Managers should consider this and seek to make improvements if possible.
Dundee had an international reputation for its exercise programmes for older people, which have been the focus of a great deal of research. The Princess Royal Trust centre was funded to provide information, support and education for carers, which was much appreciated by the carers interviewed. An Alzheimer Scotland support worker was also funded.
A pilot project had been set up by NHS Tayside with two community nurses to identify and assist people with long-term conditions who would benefit from ongoing support through case management to enable them to manage their conditions more effectively.
The intensive care at home care service ( ICAHS) had a strong rehabilitative ethos where the aim was to help older people increase their confidence and independence by encouraging them to do as much as possible for themselves. The day hospital for older people also had a strong rehabilitative approach, which ran throughout their assessment, treatment and discharge processes.
Regular reviews were normally undertaken for older people on a six monthly or annual basis, as appropriate, whether in hospital, care home or at home. These would be multi-disciplinary or multi-agency as required. Service user and carer involvement in reviews was considered to be essential by Dundee social work staff.
7.1.4 Access to services
Information about services
In the staff survey more than three quarters said there was information available to older people about health and council services. The partnership had a draft internal Service Directory, which helpfully set out a very wide range of both health and social work services but it was being updated and had not been published. When this was completed a service user booklet would be produced. There appeared to be few NHS leaflets, although there were joint leaflets on the Intensive Care at Home Service and confidentiality of patient information. The voluntary organisations had leaflets, such as the Tayside Association for the Deaf leaflet about their befriending scheme, and the Princess Royal Trust ( PRT) centre leaflets.
The Dundee carers focus group members said they had found out about services from other carers or the PRT which was funded to provide information on behalf of the department. However, they agreed that health centres were definitely improving as sources of leaflets. There was a general view amongst the carers who said that 'you had to be clear about what you wanted and strong enough to ask for it'. Managers should consider what range of information is required and take action to ensure it is widely available to the public.
The council had a First Contact Team which accepted referrals in all formats and was very accessible as it was in the centre of town. The team had no waiting times for referrals and assessments. The occupational therapy service accepted self referrals.
Improving access to services
The social work committee had approved eligibility criteria, and over two thirds of all staff surveyed said that council systems were transparent, fair and equitable. Under half said the same about NHS systems. However, evidence showed that older people did not know about or understand the eligibility criteria for services. New leaflets for services were being developed. They should include information about eligibility and priority.
There was guidance available on some aspects of collaborative working such as the Tayside joint health and social care adult discharge protocol, but there was no multi-agency guidance on referrals and transfers between health and social work services.
There was a range of specialist services, such as the Dundee Blind and Partially Sighted Society, community rehabilitation therapy ( CRT), a memory clinic, and podiatry. The involvement of Alzheimer Scotland in the Oakland day centre meant that the centre could provide for any degree of challenging behaviour, which was impressive. Access to the community health teams was through self referral, which was seen as very helpful, as well as through GPs.
Staff received regular training on sensory impairments but the council acknowledged that this was an area for improvement. Older people consulted felt that if people had needs that related to both physical and mental health problems they might have difficulty obtaining an appropriate service.
7.2 Key outcomes
Positive outcomes for older people and their carers are a key indicator of effective collaboration between agencies. The evidence showed a mixed picture. Some people whom we spoke to said they were satisfied with their services, but others were not. The findings, for example from the case file reading, showed that there were issues around achieving successful outcomes for older people, both when they were at home or being discharged from hospital. The partnership's performance was evaluated as adequate in this area.
This section should be read in conjunction with chapter 5 which considers outcomes for older people and carers on a Tayside-wide basis.
Views of older people
It was clear from the structured interviews which we undertook in Dundee that the older people interviewed were generally satisfied with the services they received. This included older people who had been effectively supported to avoid hospital admission at a time of crisis and also older people who were successfully being supported back at home after a period of time in hospital.
'I had a problem with my legs and my sheltered housing warden spoke to my GP and made an appointment for me to see him. I got some pills and I'm coping much better now. She would do anything for you.' (quote from older person in an interview)
During the fieldwork, good outcomes were demonstrated but some issues were also highlighted. On the positive side:
- An older woman who had spent a lengthy period in hospital after a below-knee amputation was secured suitably adapted alternative accommodation very quickly from a housing association. She and her husband were clearly delighted with their new housing. They also spoke positively of the Taxicard provided by the council which allowed her to maintain a degree of independence by giving her access to adapted taxis at a subsidised rate
- The positive working relationships between the hospital social work team and hospital staff ensured that older people approaching the point of being fit for discharge from hospital were able to have their needs quickly assessed
- We found a strong commitment from some staff, including those working in the Intensive Care at Home Service, to promoting older people's independence and their ability to self care.
Less positively:
- Less than half of the Dundee carers surveyed thought there was good communication between health and social care staff (although a similar proportion expressed no opinion). Less than half felt that they had involvement or input into the planning of care when the person for whom they cared was admitted to hospital. We heard a number of concerns from carers about the level of availability of respite services to support them
- We also heard a number of comments which suggested that there was a lack of clarity about the respective roles of social care and health staff in the community in the administering of medication. We observed some practice involving older people with dementia where inadequate consideration appeared to be given to their ability to retain and follow guidance on medication, given their cognitive impairment.
The findings from the case file reading exercise showed a more mixed picture than the other partnerships. For example, older people were on a waiting list for a service(s) in 25% of all the files read, but this figure was higher (33%) in NHS files in Dundee. However, most older people who are waiting for a service were already in receipt of a service, even though they were waiting for other services or a higher level of service.
Although there were only a small number (5) of cases in Tayside where the dealings with the individual were judged not to have adequately taken into account potential barriers arising from difference in culture or beliefs, all these related to NHS cases in Dundee.
7.3 Whole systems approach
There was a wide range of health and social work services. The partnership was committed to using a whole systems approach in relation to the range and quality of services, joint planning of services and joint financial management. However, there were significant issues within the partnership in relation to implementing this approach. Work needed to be undertaken on further developing clear milestones and targets, effective joint resourcing, joint financial plans, a joint commissioning strategy and joint performance measurement. The partnership had taken steps to improve this situation, for example by agreeing to implement a joint performance framework. The partnership's performance in this area was evaluated as weak.
7.3.1 Range and quality of community based services
A whole systems approach to delivering services
There was a mixed picture in Dundee about the commitment of health and social work staff to a whole systems approach to delivering services. We saw examples of good collaborative working, particularly between community nurses and social work staff at the grass roots level. However, the position about delayed discharges and the relative lack of resources impacted on joint working, with staff attributing responsibility to each other agency's use of funding and management of resources.
Broad range of quality services
Dundee council had a wide range of services to support older people in the community. Many of them demonstrated joint working in the delivery of care services for older people. These include the Intensive Care at Home Service, the Rapid Response service and the Supported Discharge Service, all of which provided additional support to people to either prevent hospital admission or support discharge.
However, the council's committee report 'Older People Services' in June 2006 stated that there were significant issues about the range of services, in relation to the level of home care, intensive home care, respite care and intermediate care. The partnership has worked to improve this situation. Its policy, following the Balance of Care report in 2003, has been to improve the level of home care, and in particular intensive home care packages, while maintaining the level of care home places. It supported this by developing more services such as housing with care, rehabilitative and respite care.
The Audit Scotland indicators for 2005-06 showed that the number of hours of home care provided in Dundee was below the national average and Dundee was ranked 19 of 32 local authorities.(It had improved from 25th in 2004-05.) In 2005-06 there was an improvement in evening and overnight care, moving Dundee from a ranking of 29 in the previous year to 26 of 32 local authorities.
The Audit Scotland figures showed that Dundee had a higher rate of service users aged over65 years than the national rate. The June 2006 committee report stated that, in total, '151 people are awaiting 1230 hours of service. Of these people, 31% are awaiting a service of over 10 hours per week'. The majority of hours were therefore awaited by people who require more than10 hours of service a week, though they were getting some service.
Managers in Dundee stated that there was an 'issue of pace' in improving the home care situation and the council has agreed an additional £1.8 million to assist in this, particularly in developing intensive home care packages of more than 10 hours per week. The committee report in June 2006 set out the issues for developing health and social work services generally across the partnership. For example, some development of housing with care had been achieved but not as much as proposed. This had added to the pressure of increasing supported care in the community and an improved balance of care.
The development of the new CHP structure in Dundee was a potential opportunity for improving the balance of care. For example, collaborative working was being developed through addressing cross-professional issues in virtual teams. However, the full potential does not yet appear to have been realised.
There were some developments which were positive. The joint equipment store, (which was at the design stage) should deliver more streamlined services but limitations in the range of equipment which can be accessed by health or social work staff would continue to limit the effectiveness of the service. There were no plans for arrangements for emergency provision of equipment or for evening access, although there were plans for weekend access.
Meeting the needs of people with dementia was mixed. Some pockets of good practice were seen particularly in the range of support from the joint community mental health teams but an overarching approach to meeting the needs of people with dementia or challenging behaviour was needed. This is also considered in chapter 5.
Dundee had a large supply of sheltered housing and there was a Best Value review of the sheltered housing service in 2005. Service user and staff surveys conducted at the time confirmed there was considerable satisfaction with the sheltered housing provided. The review also confirmed that strategic consideration had been taken of the amount required for the future. This was being taken forward as part of the Housing Strategy for Dundee.
However, we were told that much of the sheltered housing no longer met the needs of very frail or disabled older people. Many schemes had stairs to all flats which limited older people's ability to participate in community activities, although the 'Friendly Bus' service provided transport for older people so that they could travel to other sheltered housing units and community resources. Older people pointed out to us that while they liked their homes, sub-optimal sheltered housing meant they would have to move to get the care they needed and they might need a care home because their home was inaccessible.
Good practice - Dundee partnership number 2
The home care service had been re-organised so that there were small self managing teams of staff who provided the care of several older people within the team. This ensured greater continuity of care for older people and reduced the number of staff to whom they had to relate. Home care staff were able to go out with an occupational therapist when a discharge package was being planned so that there would be a good shared understanding of what was appropriate help for the older person.
The Oakland Centre provided day care for older people including older people with dementia. There were mixed views on this service. Several people saw the service as inflexible in terms of access and transport arrangements, and thought that the quality of the experience for individuals attending was limited. We were later informed that issues on access and actions to improve this had been identified by managers, who were also looking at the processes of referral and service delivery. However, during the inspection staff, service users and carers spoke positively of the support for people with dementia which was provided at the centre in conjunction with Alzheimer Scotland.
Day services for older people were also provided within a hospital setting at Ashludie and Kingscross hospitals. These services were designed to meet specific needs on a short-term basis. The Oakland Centre was seen as the base for development of day support services for older people, forming part of the continuum of support involving day hospitals.
It was not clear how these services would be jointly developed and other agencies expressed some frustration at the delays by the council in maximising the use of this resource. It was also not clear how the day support needs of older people with functional mental health problems will be addressed. However, discussions had taken place about developing day services and this would be further considered by the partnership at the Strategic Planning Group for Older People.
There were protocols and systems in place for hospital discharge planning with clear timescales for response. There was good discharge planning in the Royal Victoria Hospital and in the medicine for the elderly wards at Ninewells Hospital, but staff across agencies identified gaps in links with orthopaedic and other medical wards. The discharge process was also affected by the movement of both staff and patients in Ninewells Hospital, including the 'boarding out' of patients in temporary places within the hospital, and the subsequent lack of continuity.
Many staff in both health and social care services said that there were low levels of referrals from GPs to the teams which could support early identification of people at risk and prevent admission. This was a very significant issue since inappropriate admission to hospital can lead to a lessening of an individual's ability to cope in the community and make discharge more problematic. It should be addressed by the partnership by developing more intermediate care services.
Good practice - Dundee partnership number 3
The local manager had responsibility for mainstream home care as well as intensive home care, and the rapid response services. She had good links with combined care at home and the community rehabilitation team. This structure allowed significant flexibility in providing home-based services.
Services to support carers were patchy, particularly in the evenings and at weekends. Respite services were being developed with a plan to provide these within a dedicated respite unit. Respite for individuals was planned on annual basis and some carers found this to be unresponsive to their needs.
We spoke to staff who were very positive about the services they provided and service users who spoke highly of the services they received. A range of networks existed to include service users. We met with organisations which were developing services for minority ethnic groups and heard of involvement of service users in activity planning in sheltered housing schemes.
Service commissioning
In considering a whole systems approach to the development and delivery of services it is necessary for councils and health services to communicate well with each other and have sound commissioning strategies which show engagement with providers at an early stage.
A number of reports in Dundee had identified the imbalance in relative spending in care home places and home care, and the need to change this. This included the 'Balance of Care Report, 2003' which was commissioned by the Strategic Planning Group for Older People and had been reviewed in 2006. It set out the strategy position in terms of a commissioning framework and direction. There was an outline joint commissioning framework in place against which the partners have assessed their progress.
It was being further developed through the Best Value review led by the Chief Executive of the council, with full participation of all stakeholders, including voluntary organisations. However, there was still no agreed joint commissioning strategy for both health and social work services for older people.
Independent service providers said that there was limited contact with them both in relation to care at home and care homes, except for contract management and monitoring of services already provided. We did not find significant evidence of thinking about how the care at home market might be developed or which services were to be commissioned to promote a shift in the balance of care. Voluntary organisations said they did not feel they were treated as partners in providing services. Social work managers told us there were regular meetings with independent service providers.
Service users and staff we met were positive about the quality of home care and care home services provided by the council. The reports from the Care Commission supported this view but were concerned about the proportionately high number of complaints received about services in the private care home sector. The introduction of the national contract for care home provision will be used by the council to work with providers to deliver quality services to meet their contractual requirements.
The Best Value review of services for older people which just begun by a multi-agency group and led by the council's Chief Executive should give real impetus to developing a joint and innovative commissioning strategy. It is essential that NHS Tayside assists this process by working collaboratively to put in place a joint strategy and financial framework within which priorities for older people's services are agreed.
7.3.2 Planning, policy development and partnerships
Strategic planning is informed by a whole systems approach
A multi-agency strategy for the Dundee partnership should have an overview of service provision, show medium to long term forecasts of service needs, and be supported by a financial framework. These should be accompanied by clear action plans with achievable objectives within agreed timescales and a joint commissioning strategy. It should take account of the review of community hospitals and the development of intermediate care services.
The implementation of service planning and development of older people's services in Dundee was devolved to the Joint Strategic Planning Group ( SPG) through the Health and Local Authority Management Group. The SPG had not been meeting for some time, whilst the CHP was being set up, although it was in the process of being reconvened.
The partnership's performance had therefore been affected by delays in strategic planning. We make a recommendation about this in chapter 5.
At the time of the inspection, there was no joint strategic document which set out what health and social work community care services such as community nursing, home care and AHP services were being provided and should be developed. Nevertheless, we acknowledge that the partnership has undertaken a very considerable amount of work to develop a joint strategy.
The 'Dundee Joint Community Care Plan, 2005-08' outlined the proposed direction for health and social care services in the partnership, including those for older people, but it no longer appeared to be in line with the latest thinking within the partnership. It had been informed by the 'Balance of Care and Service Development Report, 2003', which set out an approach for older people's services and proposals for providing services. This was fully reviewed in January 2006 and specified the need for further strategic work and a full joint commissioning strategy.
Recommendation: Dundee partnership number 1
The Dundee partnership should urgently collaborate on implementing a whole systems approach at all levels of both organisations. It should produce a strategy which includes a joint action plan, financial plan, timescales and commissioning strategy, and which sets out how the partnership will meet the need for local service developments. It should also set and monitor timescales for delivering tangible results.
Both health and social work services had their own plans for services. They reflected priorities across both the CHP and council services. Dundee City Council has a detailed 'Social Work Service Plan, 2003-2007', which clearly set out services, lead officers, performance measures, funding, and target end dates, but it did not reflect the latest thinking within the partnership.
Implementation of joint vision, policies and strategies
The implementation of joint policies and strategies was taken forward in a number of ways such as the Health and Local Authority Management Group, which oversaw service delivery and development. Joint working with housing services has informed the development of the housing strategy, including housing with care and the redevelopment of sheltered housing.
The joint priority allocation meeting, which we attended, focused on care home placements, with limited discussion about how to meet the needs of people within the community requiring high level care packages. However, we also saw some positive examples of people returning to the community, after being in hospital, with increased support while awaiting the care home of choice.
There were mechanisms for involving providers in strategic planning and development of services, for example they had been offered places in strategy and service planning groups. The involvement of service users and carers in service planning was undertaken through planning processes such as Celebrate Age Network, the OPEN Project and the NHS Tayside Public Partnership Forum. There were plans to involve existing and future service users in developing new housing services. Managers said that the performance management framework was being developed to ensure that users and carers were involved more robustly.
7.3.3 Financial and resources management
Financial planning
Dundee City Council's budget for older people's services (and other services such as learning disability and substance misuse) was £31.3m in 2006-07 which, when taken together with the NHS Tayside budget of £28.4m for the Dundee area, resulted in a total budget provision of £59.7m. These budgets are aligned, not pooled.
The broad financial framework contained in the Community Care Plan set out the respective contributions to achieve joint planning commitments. This was further developed in the 'Balance of Care Review, 2006'. At different stages the council and health service have committed additional funding to meet these commitments on an interim basis, but there did not appear to be a longer term resource allocation from either agency.
The financial framework for older people's services was contained within the Extended Local Partnership Agreement ( ELPA) which set out the resources for 2004-05 and the financial framework to be operated. There was not a detailed up to date financial plan. The Agreement indicated that resource transfer would be managed by the partner agencies in accordance with the 'Tayside Resource Transfer and Bridging Finance Procedures, 1999'. We were advised, however, that this document was due to be updated.
The links between the partnership's health and social work services financial plans and strategic objectives require improvement. The construction of each year's budgets was mainly historically and incrementally driven rather than through specific links to current joint policies and objectives. The partnership ratio of financial contributions can change, to a degree, depending on the incremental construction of the budgets and whether savings are required from either partner.
We noted the debate that took place between senior managers during two meetings with us about the adequacy of resource transfer levels and the use of potential resource transfer for efficiency savings. There was discussion about the use of underspends by NHS Tayside to assist with effective management of resources.
The health board subsequently announced its intention of developing a Tayside-wide strategy for older people's services. We welcome this, but would stress the importance of developing it in full collaboration with the three councils.
At the time of our inspection, there were no medium term financial plans available for 2007-08 and 2008-09. We were advised that it was difficult to prepare such plans when decisions had yet to be taken about the Dundee City Council and NHS Tayside budgets. We make a recommendation about this in chapter 5.
Financial management
A crucial issue for the Dundee partnership was that the resources invested in older people's services, or the way they were utilised, appeared insufficient to meet the current needs of its ageing population. This was apparent from the waiting lists for services and continuing delayed discharges. This situation existed despite the fact that Dundee City Council spent 4% over the GAE level on all social work services in 2005-06.
Staff and managers in the other two Tayside partnerships told us that it was generally considered that the Dundee partnership received a proportionately higher allocation of health funding for older people's services, in order to meet shared pressures such as delayed discharges (see Fig. 3). Although council managers considered that their budgets were generally sufficient for the services that had been planned, they agreed that they were not sufficient for the unmet need.
Senior council and CHP managers clearly recognised the scale of the problems they were facing. A council committee report in June 2006, and subsequent reports, had set out the extent of unmet need for older people. It should be noted that this report provided information on numbers of older people waiting for different types of services, but did not include details of the significant amount of recurring revenue which would be required to fully address the problem. This report had also been discussed in the CHP committee, which was a positive step towards ensuring joint ownership of the problem.
The joint Health and Local Authority Management Group met monthly and financial monitoring reports were submitted to the Group on a quarterly basis. The regularity and quality of financial information provided to budget holders each period was satisfactory. Budget holders appeared to be experienced and adequately trained.
The information provided to elected members at committee meetings and the discussions that took place at the meetings appeared inadequate. However, we were advised by officers that members were also briefed, as required, prior to committees and therefore more detailed information was informally provided to them than in committee reports.
Partnership capital expenditure was minimal, apart from the provision of a joint equipment store. This was projected to cost almost £2m, with funding being provided by the Scottish Executive (£1.5m), Dundee council (£0.25m) and NHS Tayside (£0.16m). Capital expenditure requirements were dealt with by using the partners' corporate processes.
Information systems
These should support frontline staff effectively, and a new council IT system, called Event Recording System ( ERS) had been developed in-house and introduced in July 2005 to do this. About 550 staff were using it to record a range of event types such as referrals, assessments and phone calls. SSAs could only be held as attachments, which limited the potential to draw statistical summaries from them. It did not assist inter-agency communication because it was an in-house only system.
Staff in Dundee were particularly concerned about the problems with the interface of health and social work systems. They spoke of their considerable frustration in the delays in achieving co-ordination between systems, the duplication in recording for both systems and the fact that they had to fax lengthy documents to each other. Developments were underway to link the health and social work IT systems and the Dundee Data Partnership was monitoring this. Staff were not aware of an agreed timescale for achieving the links between the two systems.
There were several joint and council groups which worked to ensure that joint and single agency information systems were developed and implemented. These included the Dundee Data Partnership and the Social Work Department's Service Information and Technology Group.
7.4 Delivery and management of services
The effectiveness of day to day planning and resource management between health and social work varied considerably within the local services. It was most positive in those services focused on discharging individuals from hospital and in the relationship between home care staff and community nurses. Staff perceived it as problematic when resources were not available to provide complex or high cost care packages for individuals, particularly when leaving hospital, which then contributed to the numbers of delayed discharges. Performance in this area was evaluated as adequate.
7.4.1 Day to day planning and resource allocation
Operational management and planning
Health and social work managers considered that the systems in place to support the day to day planning and delivery of services were very good. These systems were designed to ensure that services were provided in line with agreed joint plans and priorities. For example, the Health and Local Authority Management Group jointly oversaw management and planning of services.
Individual, unit and team service plans set out their respective objectives and the links to the council's departmental service plan. Service managers for older people's services had defined operational and functional responsibilities, including areas of joint responsibility, and these were directly linked with service plans.
We agree that there were some sound internal mechanisms. For example, we were impressed with the fact that senior home care managers were not involved in day to day planning and resource allocation but had empowered middle and front line managers to deliver the service. Health managers were implementing nurse-led discharges giving ward based staff more responsibility in patients' journey of care in hospital.
Good practice - Dundee partnership number 4
Ward based nurses were being encouraged to take responsibility for individual patient's care journey and discharge arrangements from the point of admission. They identified lead workers from either discussions with the family or from contacting social work and then worked with them to provide seamless care. This can be difficult to manage in Ninewells where patients may be 'boarded out' to other beds.
The First Contact team screened and prioritised social work referrals in Dundee and this service worked well - referrals were generally handled within half a working day. If not resolved within six weeks, cases were then passed to long term teams. Guidance was in place for firstline managers and practitioners that included eligibility criteria, devolved budgets, direct access to resources, the joint SSA process, and care and assessment standards.
We were not convinced that there were consistently strong managerial and staff links between the agencies in relation to day to day planning of services, case allocation and joint planning for the care of individuals. Some social work staff and managers said they did not know details of waiting lists for services, although we saw electronic evidence of waiting lists that have been available and circulated to staff for 18 months and for four years in the case of delayed discharges. Their statement was in line with our concerns that health and social work managers, until recently, have not been proactive in jointly managing waiting lists for some services for older people. These services include crisis, rehabilitative, respite and home care.
Workload management systems and waiting times
Dundee City Council had effective mechanisms for workload management of social work in place and we were not made aware by staff of any significant problems with workloads. However, day to day joint management of workloads was not wholly effective, as targets such as those set out in the Local Improvement Targets ( LITS) were not all being met, although there were other factors contributing to this.
In June 2006, the Social Work Department reported to committee that there were 145 older people waiting for care at home. Of these, 19 people had been waiting less than six weeks and 70 people had been waiting more than six weeks for a home care service. The report states 'although the majority have some service, those awaiting high levels of service are very vulnerable to arrangements breaking down'. In addition, 79 people were waiting for care home placements. In October 2006, there were 39 older people who had been waiting in hospital for discharge for over six weeks and 15 for less than six weeks.
Health staff such as GPs, consultants, hospital and community nursing staff said it was difficult to know where decisions on waiting lists were made and were particularly concerned about the waiting times for residential homes and the availability of respite.
There were limited waiting lists for community equipment and the relevant manager stated this positive situation existed because the occupational therapists ( OTs) employed by the council did not undertake care management and could focus on providing their service. Health staff said there was an immediate response by community OTs to their faxed referrals for same day discharge of patients in acute care when returning home.
Waiting times for health services, such as physiotherapy, within the CHP were rigorously monitored and actions taken if national waiting times targets were to go unmet. There was no waiting list for Ashludie Day Hospital; staff there allocated days for patients and decided the appropriate treatment.
There were different mechanisms within the partnership for handling the allocation of services. An inter-agency group prioritised the allocation of resources to meet individual needs for complex or high cost care packages such as care home places. There were regular functional frontline management meetings in social work that considered the information in relation to the capacity and workload at team and service level.
However, many staff thought that if a service was not available or there was a waiting list, then social work staff filled in unmet needs forms and accepted the fact that a service would not be available. We were aware that unmet need was reported to committee and that additional resources had recently been allocated to alleviate pressure on waiting lists.
Joint working was most positive in those services focused on discharging individuals from hospital. There was a very strong partnership between the Intensive Care at Home Service ( ICAHS), the Crisis Team and the discharge co-ordinators in Ninewells Hospital. The ICAHS manager had considerable autonomy in identifying what service users needed and could manage services flexibly and positively to provide it quickly and effectively. Preventative and rehabilitative social work staff said they had excellent relationships with health colleagues in acute services but there were difficulties when there were not enough services to meet individuals' needs.
There were also strong relationships within joint teams. The Crisis Team described itself as 'a coherent team - we're good at dealing with things ourselves - we work through our difficulties'. They had developed innovative work patterns to maximise coverage. Home care staff said they worked very closely with community nurses who would take referrals from them and respond within one day: 'We work closely with the district nurses'.
Concerns were expressed by social work staff about the fact that there were very different referral patterns from GP practices in Dundee, together with a growing sense of detachment and distance between them and the GPs. They said: 'It is not going to get any better'. They believed that the new GP contracts and out of hours arrangements meant that doctors were being called out to see patients whom they did not know and would be more likely to admit to hospital.
They identified GPs as potential allies and thought that closer joint working would help to prevent inappropriate admissions to hospital. They also recognised that it was essential to have good preventative and crisis services for older people in the community if this was to happen. We were concerned to find a perception by front line staff that working relationships with GPs were deteriorating and consider that the partnership should take action to reduce barriers to closer co-operation.
Both health and social work had appropriate systems for monitoring demand and unmet needs. This information was collated and distributed regularly, for example Citystats were regularly reviewed by NHS Tayside and waiting times were regularly reported to Dundee City Council.
However, there were occasions during the fieldwork when we were concerned that some managers in both agencies seemed to have lost sight of what it meant for the individual older person who was waiting for services. Figures for waiting lists and delayed discharges were quoted without conveying to us a sense of urgency to act together at a strategic level to address the issue.
Senior managers were clear that this was not so, stating that they monitor, review and report service provision and waiting lists. Moreover, they said that they have frequently conveyed the urgency of the situation and it is in recognition of the problems that a Best Value review was being undertaken.
7.4.2 Risk management and accountability
This section deals with risk management and accountability specifically in relation to inter-agency working regarding individuals. Organisational risk management issues were not covered in this inspection. Established multi-disciplinary arrangements for the protection of vulnerable adults should be in place. These should include a fully implemented inter-agency policy and procedure for the reporting of abuse of vulnerable older people.
Arrangements
A Tayside-wide protocol had been put in place in 2005 for the protection of vulnerable adults. Further work, such as leading workshops, was being undertaken by the national Joint Improvement Team ( JIT), to improve the implementation of the protocol. This should also ensure greater consistency about the threshold for intervention, assessment and management of risk across Tayside.
A multi-agency Adult Protection Committee was being established in Dundee. Several risk assessment forms had developed by health and social work, for example by Ashludie day hospital and Oakland day centre.
Managers said that comprehensive multi-disciplinary training was delivered locally in Dundee. The care management training to be implemented following the new Scottish Executive guidance will also include risk assessment and the protection of vulnerable adults.
Accountability for risk management
The accountability for risk management and monitoring of risk assessments was undertaken through multi-disciplinary case conferences, supervision, assessment, care and case management processes and case file audits. For example, assessment documents included triggers for identifying and responding to risk.
Dundee managers and staff said they took a person-centred approach to assessment and care planning to ensure that each person had a care package appropriate to their needs. This included carers support services and advocacy services funded by Dundee. In this way an appropriate balance between risk management and right of people to make their own decisions was ensured.
However, they also told us that there were issues in Dundee about individuals being admitted to Ninewells Hospital, rather than being supported in their own homes, for a number of reasons. There was a local expectation by carers and families that individuals would be admitted, for example in emergency situations or when carers were having difficulty coping. This was reinforced by the relative ease of access to Ninewells Hospital, for example by GPs, and less readily available home-based support services, both health and social work, in Dundee. These issues require a whole systems approach by the partnership if they are to be resolved.
7.4.3 Management and support of staff
Training and staff development
Under the leadership of the Director of Social Work, the department has worked very hard to improve the staffing situation, including training and support. There had been some significant successes, such as reductions in levels of sickness, staff turnover and vacancy levels.
Emphasis was placed on both supporting and enabling staff, for example through personal folders, achieving the Scotland's Health at Work ( SHAW) silver award and through actively promoting healthy living for staff. Independent counsellors, leaflets, emails, notice boards and the non-smoking policy all reinforced the message about the value of staff and the importance of their good health.
Training and continuous professional development ( CPD) were largely agency-specific. There were no overall joint training strategies and no indication of close joint working between the training managers in health and social work. In discussions with social work managers, they focused on the improvements that had been made in social work training and staff matters.
There were a number of single agency training developments. A revised induction programme for all community care staff which would complement the existing two week induction programme for home care staff had been devised and will be implemented. An induction programme for care home staff had been introduced. A social work development framework was in place and an implementation plan for this specifically for community care was being progressed.
There were some local inter-agency initiatives such as joint induction programmes for health and social care staff in joint teams. The earlier SSA training involved health and housing (specifically homeless services) staff. A new single shared assessment training programme had been devised and will be implemented. The joint care management training development group had planned for and will implement the national care management training framework. Home care managers were proud that they had undertaken joint training between home care staff and community nursing staff in a move towards greater sharing of duties and eventually more generic workers.
There was a specialist mental health induction for community mental health and social care staff alongside specialist palliative care and rehabilitation training. Staff in Ninewells Hospital were to have a laminated and easy-to-read card for the discharge pathway and trained nurses would walk the wards advising people about the pathway.
The independent sector said that access to the council's training was very limited. The council had recognised that there were deficits in the quality of some independent care homes in Dundee and had developed in-reach work to train and support staff in the delivery of services to older people with challenging behaviour.
There were excellent opportunities for unqualified staff to access training through the Healthcare Academy and the Social Work Academy but these were only open to health or social work employees respectively. They appeared to be targeting the same workforce.
Joint workforce planning
Joint workforce planning did not appear to have been considered by the partnership. However, issues, such as demographic trends and the age of the workforce, indicate that the partnership should begin to undertake joint planning.
Managers from health and social work spoke of the great difficulty they envisaged in progressing to becoming a single employer, but they had held joint interview panels for some joint posts. Managers said there were multi-agency teams in Dundee which were working satisfactorily but they stressed the importance of staff being clear at the start of setting up a joint team, or when joining it, about factors such as holidays and conditions of service.
Single Status and Agenda for Change have led to some diversion between the agencies about differing health and social work job descriptions. Managers were trying to streamline these where appropriate, for example for the multi-agency and multi-disciplinary staff working in the joint equipment store.
Checks on qualifications and registration requirements were made at the recruitment stage, including Disclosure Scotland checks in both health and social work. Staff have personal development plans that took account of their CPD requirements for accreditation purposes.
Staff support and morale
The Social Work Department has worked hard to promote the health and well being of its staff through a range of activities such regular health events, information about smoking cessation, and health checks in working time. It achieved the Scotland's Health at Work ( SHAW) silver award in April 2006 and was working towards the gold award.
The emphasis on improving staff morale, led by the Director, was particularly effective in home care, with staff often going the 'extra mile'. The department's arrangements, for example access to stress management and back care, have led to a significant reduction in days lost through sickness. In home care, a combination of these and the positive effect of small self-managed teams have reduced the sickness level to 3%, which is very commendable.
There were good relationships in the multi-agency teams, such as the Intensive Care At Home Service ( ICAHS) where working relationships were very positive and there was a clear commitment to sound multi-agency working. Team members described themselves as 'one team, committed and confident about the services we provide'.
Policies that guide how staff communicate
The department was developing a Communication Framework to improve the way staff communicated with each other, mainly within the council, and engaged with service users and their carers. We were not made aware of a similar initiative in the CHP.
Communication between staff in the Dundee partnership appeared to be variable. The majority of staff surveyed agreed that services worked well together to deliver services. We met with staff based in both hospital and community settings, for example in the Crisis Team, who could evidence positive collaborative approaches to support discharge from hospital and support individuals in the community. But some staff in preventative and rehabilitation services said they had mixed relationships with health colleagues in acute services. There was a lack of consistent staffing and the 'boarding out' of patients in temporary places within Ninewells Hospital had led to difficulties in developing working relationships.
Many council staff said that poor communication from health, and particularly from colleagues in the acute sector, was affecting the quality and speed with which some referrals about discharging older people from hospital were being made to them. They said training and guidance on moving patients from hospital appeared to be lacking for health staff, again particularly in acute services.
'It is becoming increasingly difficult to engage effectively with GPs and district nurses. We have seen a dramatic drop in referrals from district nurses since the inception of SSA.' (quote from Dundee staff survey)
Staff generally found it difficult to understand the delays in putting care packages, especially complex ones, in place. They were very aware of the implications of this for older people themselves, and for them as staff being able to offer a service to other older people. In the staff survey, 79% of social work staff in Dundee agreed that multi-agency discharge arrangements are successful in preventing inappropriate admissions but only 53% of NHS Tayside staff agreed.
Home care staff said their teams met every morning to discuss workloads, for example on how to handle emergencies, sickness cover and training and they were more positive about joint work with health colleagues, saying they worked very closely with district nurses who would take referrals from home care staff and respond within the day.
'We are proud of the work we do with our colleagues in housing and health. We have good links with the hospitals and we work hard at keeping relationships going.' (quote from Dundee staff survey)
Union representatives said that links between health and social work unions tended to be arms-length in Dundee and there was no joint staff forum, although there had been one in the past. They said that relationships between health and social work staff were not generally as good as elsewhere in Tayside, although there had been good joint working in the development of the joint equipment store.
Recommendation: Dundee partnership number 2
The partnership should work to develop a more integrated approach to training, workforce planning and methods of communicating with staff about services for older people.
7.4.4 Performance management and continuous improvement
Joint performance reporting
Joint performance reporting was undertaken by the Joint Performance Management Group through the national reporting mechanism, the Joint Performance Information and Assessment Framework ( JPIAF). This consists of annual returns by partnerships on performance indicators based around four national outcomes. They are underpinned by Local Improvement Targets ( LITS) which are set by the partners themselves to measure progress and improvement.
The Scottish Executive requires reports from local authorities and the NHS about how they are working in partnership and what outcomes are being achieved as a consequence for older people. In response to the partnership's JPIAF submission for 2005-06, the Executive rated the partnership as making steady progress overall.
The partnership was rated as making good progress on single shared assessment in terms of the number of older people with completed community care assessments and an average timescale of 19 days between the completion of assessments and start of first service. The evaluation identified the need for further work to be done on IT systems and the need for further involvement of a broader range of assessors, for example housing staff.
The partnership was rated as making steady progress in relation to cross-agency access to resources as a means of enabling faster access to services for older people. A joint resourcing agreement and eligibility criteria were being developed.
In terms of whole systems working, the partnership was evaluated as below average on the comparative model. Whilst there had been improvements, for example a reduction in hospital admissions and an increase in intensive home care, there had been an increase in multiple emergency admissions to hospital and delayed discharge targets had not been met.
The evaluation concluded that whilst the balance of care was improving, 'there is still a long way to go'. This was evident from the fieldwork where we saw that the partnership was continuing to fall short of its delayed discharge targets. It also became clear that the partnership would have to overcome significant financial pressures if it was to make further progress in shifting the balance of care.
Overall, the partnership was evaluated as falling short of its Local Improvement Targets for 2005-06. Whilst there had been improvements in performance on reducing emergency admissions and intensive home care, performance in these areas still fell short of the targets which it had set. Its new targets for 2006-07 were evaluated as being sufficient.
The Social Work Department has already used the EFQM model, which is closely aligned to SWIA's Performance Inspection Model ( PIM), to assess is own performance. The partnership had agreed to use the PIM as the basis for the Joint Performance Management Framework, which would be managed by the Joint Performance Management Group. The Framework was still at an early stage and the partnership was further developing it, for example by holding a second joint strategic planning event in November 2006.
There were a number of mechanisms through which the partners individually monitored performance. The CHP used the Quality Improvement and Clinical Governance reporting structure and calendar which is used throughout NHS Tayside. It reported on these at six-monthly intervals. Particular attention was being given to waiting times.
Through these joint and single reporting mechanisms the partners were able to demonstrate improvements such as an increase in the number of people receiving intensive home care (more than 10 hours per week) and the need for further improvements, for example in reducing delayed discharges and the number (about 50) of people not receiving an intensive home care service, as at June 2006.
Continuous improvement
There was evidence of continuous improvement. The Intensive Care at Home Service, ( ICAHS), heard of older people being admitted inappropriately to Ninewells Hospital. Team members 'walked the job' for two weeks, including out of hours and at weekends. Although they had found little evidence to substantiate the statement, they had established a closer relationship with the A&E department, which included a co-ordinator visiting A&E on a daily basis as well as screening referrals from there.
Both partners regularly reviewed older people's services, for example the council was in the process of undertaking a Best Value review of older people's services, due to be completed in January 2007. It was being led by the Chief Executive with wide ranging and multi-agency representation. There had also been a review of sheltered housing. The review of occupational therapy services in 2005-06 had led to a number of improvements including revised targets to reduce waiting times for adaptations.
The use of community hospitals was being reviewed by NHS Tayside. The partnership also intended to review single shared assessment processes and documentation.
There were some examples of best practice being jointly identified and rolled out, for example in relation to the joint equipment store, where managers had looked at other stores in Scotland in order to learn about the critical success factors.
Service user/patient feedback was sought, for example in the home care service and by the Crisis Service and Early Supported Discharge Team which used a tick box form for regular, city-wide surveys of patients. These demonstrated high levels of satisfaction. The EFQM model has customer results as one of its main drivers and should promote a user focus when the Joint Performance Management Framework is well established.
Overall we did not find that there was a culture of joint performance management or continuous improvement fully embedded in staff and managers' thinking. The Audit of Best Value and Community Planning carried out by Audit Scotland in 2005 stated that: 'the department has made strong efforts to drive a new culture of performance management that is beginning to show encouraging results'. We recognise the significance of the recent adoption of a shared Joint Performance Framework and the two development events in June and November 2006. These should have a significant impact on co-ordinating efforts to deliver better services and support partnership working.
7.5 Leadership and direction
The leadership of the Dundee partnership was evaluated as adequate. There were many good quality services which had been planned and delivered on a joint basis and which reflected well on the partnership leaders. There was commitment and enthusiasm amongst frontline staff for their work, despite some low morale. Some initiatives planned jointly by the council and the CHP were a positive sign of improving strategic leadership.
The need for improvement in this area mainly reflects the problems in meeting the needs of older people, the difficulties in jointly resolving these issues by the council and NHS Tayside and the quality of relationships and communication amongst some of those at the most senior levels.
Elected members in Dundee City Council, whom we met during the inspection, clearly valued the social work services provided for older people and stated a strong commitment to meeting the needs of older people. Members also saw the CHP as a key mechanism for linking the local authority in to the health inequalities agenda.
The Convenor of Social Work has had a long standing personal interest in this area and was also a member of the NHS Tayside board, though she was uncertain about the usefulness of this role. Members (and some senior officers in both health and social care) did not convey a sense of strong partnership between the council and NHS Tayside at the most senior level. There was some evidence that relationships at this level were not always marked by mutual trust.
The council had taken the bold step several years ago of reducing its in-house residential provision from ten units to five. They have approached the modernisation of the home care service at a slower pace. Members also acknowledged that some of their sheltered housing needed to be upgraded or replaced to ensure it was suitable for older people with greater levels of need. They described a strategic approach to all social work services that had a strong emphasis on low-level preventive services and health and well-being.
Senior council and CHP staff clearly recognised the scale of the problems they were facing. The council committee report in June 2006, and subsequent reports, had set out the extent of unmet need for older people, although it should be noted that this report provided information on numbers of older people waiting for different types of services, but did not include details of the significant amount of recurring revenue which would be required to fully address the problem. This report had also been discussed in the CHP committee, which was a positive step towards ensuring joint ownership of the problem.
Other ways in which the partners were trying to develop a more joint strategic approach included agreement by the council and the CHP to a joint performance framework, the joint development of intermediate care, and a proposal to bring community planning and community care planning closer together. The CHP Manager confirmed that there had been improved relationships with many council departments since the inception of the CHP and a greater understanding of council functions. He also thought health issues had a bigger profile within the council.
There was a very significant resource shortfall in council funding of older people's services which was leading to lengthy waiting times for most services and to increased delayed discharges. The council attributed this to the need to fund children's services above the indicative GAE level from the Scottish Executive. The council had made funding of £1.8m available to alleviate the problem in older people's services. The council had also taken the positive step of initiating a Best Value review of older people's services, led by the Chief Executive.
However, many meetings which we attended were dominated by discussions about funding shortfalls and which agency had responsibility for solving the problem. On two occasions there was debate amongst senior managers about funding arrangements such as previous levels of resource transfer, together with the use of underspends by NHS Tayside to assist with the effective management of resources.
These discussions and other related matters raise serious concerns about the transparency of arrangements, particularly around resources, between the two organisations and the capacity of the leadership to resolve these problems.
One senior council officer acknowledged a lack of collective vision for older people, which was confirmed by the results of the staff survey and in focus groups. Acute services staff from Ninewells Hospital strongly expressed a view that there was no agreed vision for older people in the hospital and that they were seen as a low priority. Other health staff also expressed concerns about the commitment to the care of older people within Ninewells Hospital.
All senior staff and clinicians agreed that there was an urgent need for a joint older people's strategy for the Dundee partnership, underpinned by an investment strategy. Strong and visible leadership on the part of both organisations will be required if this is to be achieved.
7.6 Capacity for improvement
The evaluation of capacity for improvement is based on three key factors: demonstrable improvements in outcomes for people who use services and their experiences, quality assurance and performance management, and the effectiveness of leadership at all levels in health and social work services.
We found that there were generally good outcomes for people using services. Senior managers recognised that quality assurance and performance management needed more attention and had agreed how this would be undertaken. The joint leadership of the Dundee partnership was not as strong or as positive it could have been and we therefore evaluated the capacity for improvement as adequate.
In order to maintain progress there are a number of positive factors which will underpin and support these developments. Both health and social work staff were motivated to work together to provide the best possible outcomes for older people and their carers and wanted to see improvements being made where there were difficulties. There was very strong support from the council which valued social work services highly. There was a strong ethos in Dundee about enabling well being and self care and the council prided itself on the availability of lower level supportive services.
The partnership in Dundee faces very significant challenges and therefore requires strong leadership and high levels of commitment. These challenges, including the financial ones, should not be allowed to get in the way of achieving better outcomes for older people. There is evidence of some good collaborative working between NHS Tayside and the council, but it is essential that the two organisations make sure this is universal and that priority is given to resolving difficult issues as quickly as possible. Only through this can everyone be assured that the needs of older people will be met in the most effective way possible, in line with 'Delivering for Health' and 'Changing Lives'.