Follow your hunch

In the past, social care practitioners may well have had cause to
wonder at the stream of unpiloted and unevaluated initiatives they
are expected to put into practice. But a new programme for older
people in London is using a revolutionary approach -Êasking
the people who actually provide services to come up with innovative
new ways of working, and carefully evaluating the results.

The London Older People’s Programme was launched in Autumn 2001, a
joint initiative established between the Social Services
Inspectorate and the NHS’s Directorate of Health and Social Care
(London). In headline terms, it is the capital’s response to the
National Service Framework for Older People and part of
government’s wider “modernising” agenda.

But behind the jargon, this pan-London experiment is working at
grass-roots level to develop more intuitive, responsive and
co-ordinated services. Essentially, this two-year, two-phase
programme is testing out a key part of the NSF -Êstandard 2,
which talks about the importance of person-centred care.

The idea is that care services should flow seamlessly around the
older person. A central part of this is the single assessment
process, which is a multi-disciplinary assessment of an older
person’s health, environment and social care needs. The projects
within the London programme aim to support the use of the single
assessment process by piloting small-scale innovations in the way
services are provided, in various settings including hospitals,
communities and intermediate care.

The London programme uses a tried and tested way of assessing
services and improving outcomes that involves focusing on a small
number of individual cases and identifying the barriers to a
seamless service in each case. Over a number of cases, staff
develop a hunch about what factors are causing problems, and come
up with possible solutions. These solutions are then tried out with
small numbers, assessed and then tried more widely. But whereas
this collaborative methodology is well established in health
settings, people involved in the London programme are faced with
the much more complex, multi-dimensional relationship between
health and social care.

In the programme’s first year, 13 care communities in London
boroughs were selected as pilots, with a further 12 boroughs coming
on board in 2002. Care communities include a whole range of
statutory and voluntary services from acute health services and
social services to occupational therapists and physiotherapists.
Each of the 25 projects has appointed a project manager -Êa
local champion and co-ordinator -Êpaid for by the programme,
which has a budget of less than £2m over two years. Of this,
£1.6 million has been given to the projects as seed funding,
with the remaining £300,000 spent on the co-ordinating team,
workshops and training.

Project managers are responsible for working with individual teams
in health and social care settings to try -Êon a small scale
-Ênew approaches to the care of older people. The work of each
project is typically supported by “strategic groups” of senior
managers and “working groups” of front-line staff and
practitioners.

Each project focuses on one of two different approaches to
person-centred care. The first is case management. Case managers
work with a specific group of older people -Êusually those
with a range of chronic health problems and social care needs
-Êand work in a holistic way supporting the older person to
manage their own situation and become more independent.

This form of case management has enormous benefits for the older
person and potential cost savings where independence can be
maintained. It is extremely skilled work, and very labour intensive
for the staff involved, but is generally only applicable to a
relatively small number of older people and is time limited to
around 10 weeks.

Redbridge Council is one of the second phase of pilots, and project
manager Rebecca Hadley started work identifying potential pilots
and setting them in motion this summer. She says: “We’ve found that
when we ask the teams to identify people who would benefit, they’ve
been very enthusiastic and keen to get involved.”

Redbridge has two older people who are being case managed within
the project and both have high needs. The criteria the project
selected for older people to be involved were that they were
over-75, in need of at least 25 hours of care per week, had been
taken to accident and emergency twice in the previous 12 months,
and were on four or more medications.

The Redbridge project is also involved in piloting a new approach
to the role of care co-ordinators, whose job is to pull together
the package of care following the single assessment. Hadley is
involved in piloting the use of non-professionals as care
co-ordinators, with a working title of “older person’s link
worker”. This division of labour enables professional staff such as
social workers and occupational therapists to focus on their area
of expertise, and the post of “link worker” could also help to
develop a new career pathway for non-professional staff.

The second approach is the case finding model -Êwhere older
people are screened by telephone or in person to identify any needs
they have. This approach makes contact with many older people who
may not be aware that there is help available for them, and staff
follow up about one in 10 older people whose responses indicate
they may have undiagnosed health problems or unmet social care
needs. Case finding approaches have helped identify people with
undiagnosed heart disease and prostate cancer, as well as helping
other people obtain services like chiropody and claim the benefits
they are entitled to.

There have been significant improvements for older people within
pilots already. One man’s panic attacks and breathing difficulties
had resulted in no less than 32 visits to A&E in one 12-month
period. Yet following on from his single assessment, he built a
relationship with his case manager, whose support and reassurance
over the phone have meant that he can control his own symptoms to
the extent that he has only been to A&E once in a three-month
period. Staff on the acute side are very impressed with one A&E
worker saying the programme has provided “conclusive proof that
joint working and co-ordinated care can have enormous benefits for
local services, but more importantly can provide a holistic and
greatly improved care pathway for the patient”.

Dave Walton and Kerry Gilmour joined the programme in July 2002 as
programme managers -Êresponsible for supporting the 25 care
communities in the programme. They feel the great strength of the
programme is its flexibility and the focus on manageable changes.
Pilots can try out new approaches to find out what really works,
what things are necessary and which can be changed or omitted. And
an important part of the programme’s work is sharing and learning
from experience, and disseminating the results. Individuals
involved in the pilots talk to other team members who are not
involved, thus spreading information and good practice examples to
a far wider group of practitioners. As one of the leaders of the
programme, Elizabeth Lowe, puts it: “It’s about good practice
becoming common currency.”

The programme comes to an end next summer. When the funding runs
out, some pilots may prove to be sustainable in the longer term,
others may not. But the aim of the project was to establish
evidence-based good practice within the NSF and the single
assessment process, and to that end the programme has been subject
to rigorous evaluation. King’s College, in London, is currently
evaluating the second phase pilots, which should produce some good
quality evidence on which to base practice. With this to build on,
older people’s experience of health and social care services in the
capital could eventually be changed beyond recognition. 

– For further information on London Older People’s Programme go to
www.london.nhs.uk/olderpeople